Private Health Insurance (Benefit Requirements) Amendment Rules 2009

Administered by Department of Health, Disability and Ageing

Legislation au F2009L00688 Rules Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

 

Issued by the Authority of the Minister for Health and Ageing

 

Private Health Insurance Act 2007

 

Private Health Insurance (Benefit Requirements) Amendment Rules 2009

 

Section 333-20 of the Private Health Insurance Act 2007 (the Act) provides that the Minister may make Private Health Insurance (Benefit Requirements) Rules providing for matters required or permitted by Part 3-3 of the Act, or necessary or convenient to be provided in order to carry out or give effect to Part 3-3 of the Act.

 

The Private Health Insurance (Benefit Requirements) Rules 2008 (No. 2) (the Rules) (as amended), which commenced on 1 July 2008, provide for the minimum benefit requirements for psychiatric, rehabilitation and palliative care and other hospital treatment. Schedules 1 to 5 of the Rules set out the minimum levels of benefit which are payable for hospital treatment.  Namely, benefits for overnight accommodation (Schedules 1 and 2), same day accommodation (Schedule 3), nursing-home type patients (Schedule 4) and second tier default benefits (Schedule 5).

 

The Private Health Insurance (Benefit Requirements) Amendment Rules 2009 (the Amendment Rules) amend Schedule 3 of the Rules to reflect changes in Medical Benefits Schedule (MBS) items which commenced 1 February 2009. The purpose of the amendments to Schedule 3 is to include new MBS item numbers in Part 3 - Type C Procedures.

 

Type C procedures are those procedures for which hospital treatment is not normally required. Minimum benefits for either overnight accommodation or day-only accommodation are payable for patients receiving certified Type C procedures where the certification requirements in the Rules have been satisfied.   

 

Details of the Amendment Rules are set out in the Attachment.

 

Consultation

 

The changes to the MBS resulted from reviews by the Medicare Benefit Consultative Committee (MBCC) and the Medicare Services Advisory Committee (MSAC).  The MBCC is an advisory committee established by agreement between the Minister for Health and Ageing and the Australian Medical Association. MBCC’s major function is to review particular services or groups of services in the MBS, including consideration of appropriate fee levels.  MSAC advises the Minister of new and emerging medical services and under what circumstances public funding, including listing on the MBS, should be supported.

 

No specific consultation was undertaken in relation to the amendments to Schedule 3 of the Rules because the changes were machinery in nature and did not substantially alter existing arrangements.  The amendments to Schedule 3 are part of the ongoing management of the Private Health Insurance (Benefit Requirements) Rules.

 

 

PRIVATE HEALTH INSURANCE BRANCH

DEPARTMENT OF HEALTH AND AGEING

FEBRUARY 2009

ATTACHMENT

 

DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2009)

 

1. Name of Rules

 

Rule 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2009 (the Amendment Rules).

 

2. Commencement

 

Rule 2 provides that the Amendment Rules are to commence on the day after they are registered.

 

3.              Amendment of Private Health Insurance (Benefit Requirements) Rules 2008 (No. 2)

 

Rule 3 provides that the Schedule to the Amendment Rules amends the Private Health Insurance (Benefit Requirements) Rules 2008 (No. 2) (the Rules) which commenced on 1 July 2008, and were subsequently amended on 18 July 2008, 20 September 2008, 1 November 2008 and 20 December 2008.

 

Schedule – Amendments

Item 1 – Schedule 3, Part 3, Clause 8 Interpretation, Items in the Diagnostic Imaging Services Table

Clause 8 of the Rules provides that a Type C procedure is a procedure specified in clause 8 by reference to MBS items. 

 

Item 1 of the Schedule of the Amending Rules amends clause 8, Part 3, Schedule 3 of the Rules to insert new MBS item numbers 61541,              61544, 61553, 61556, 61565 and 61568 at I4 – Nuclear Medicine Imaging. This insertion reflects new MBS item numbers that were created in the Health Insurance (Positron Emission Tomography) Determination 2008 (No.2) which was made under section 3C of the Health Insurance Act 1973 (HI Act). Under section 3C, these new MBS item numbers are to be treated as if they were items in the Health Insurance (Diagnostic Imaging Services Table) Regulations 2008 (Diagnostic Imaging Services Table). The new MBS items commenced on 1 December 2008. 

 

Item 2 – Schedule 3, Part 3, Clause 8 Interpretation, Items in the Diagnostic Imaging Services Table

Clause 8 of the Rules provides that a Type C procedure is a procedure specified in clause 8 by reference to MBS items.

 

Item 2 of the Schedule of the Amending Rules amends clause 8, Part 3, Schedule 3 of the Rules to insert new MBS item numbers 63464 and 63467 at I5 – Magnetic Resonance Imaging.  This insertion reflects the new MBS item numbers in the Diagnostic Imaging Services Table. Under the Health Insurance (Diagnostic Imaging Services Table) Amendment Regulations 2008 (No.4), these new MBS items commenced on 1 February 2009.

 

PRIVATE HEALTH INSURANCE BRANCH

DEPARTMENT OF HEALTH AND AGEING

FEBRUARY 2009

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules 2009 were enacted to amend the Private Health Insurance (Benefit Requirements) Rules 2008, specifically updating the minimum benefit requirements for certain diagnostic imaging procedures. These amendments were necessary to reflect changes to the Medical Benefits Schedule (MBS) which were made in February 2009. The Private Health Insurance Act 2007 empowers the Minister for Health and Ageing to make rules concerning the benefit requirements for private health insurance, and these amendments were made to ensure consistency between the MBS and the benefit requirements outlined in the Act. The objective of these rules is to ensure that private health insurance policies provide appropriate coverage for new diagnostic imaging procedures as they are listed on the MBS. These amendments were introduced by the Minister for Health and Ageing and were overseen by the Department of Health and Ageing.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2009 amends the Private Health Insurance (Benefit Requirements) Rules 2008, which set out the minimum benefit requirements for psychiatric, rehabilitation and palliative care, and other hospital treatment. The Amendment Rules specifically update Schedule 3 of the 2008 Rules to include new Medical Benefits Schedule (MBS) items that commenced on 1 February 2009. These amendments relate to Type C procedures, which are those for which hospital treatment is not normally required. The changes ensure that the minimum benefits for either overnight or day-only accommodation are payable for patients receiving certified Type C procedures, provided the certification requirements in the Rules are met. The amendment process was conducted without specific consultation as the changes were administrative in nature and did not substantially alter existing arrangements. The Private Health Insurance (Benefit Requirements) Amendment Rules 2009 apply to private health insurance providers and consumers within Australia, aiming to align the benefit requirements with updated MBS items.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules 2009 (the Amendment Rules) amend the existing Private Health Insurance (Benefit Requirements) Rules 2008 (No. 2) by updating the minimum benefit requirements for certain hospital treatments in line with recent changes to the Medical Benefits Schedule (MBS). Specifically, the Amendment Rules adjust Schedule 3, which pertains to minimum benefits for same-day accommodation procedures. These changes incorporate new MBS item numbers into the category of Type C procedures, which are medical procedures for which hospital treatment is typically not necessary. For instance, MBS item numbers 61541, 61544, 61553, 61556, 61565, 61568, 63464, and 63467 are now included in the Diagnostic Imaging Services Table and are recognized in the Rules as Type C procedures. The Amendment Rules impose specific obligations on private health insurers to comply with the updated benefit requirements set out in Schedule 3. Insurers must ensure that they provide the minimum benefits specified for the newly included Type C procedures when these procedures are certified as required. This includes paying the appropriate benefits for either overnight or day-only accommodation for patients receiving these procedures, provided the certification criteria outlined in the Rules are satisfied. Compliance with these updated benefit requirements is crucial to ensuring that policyholders receive the correct level of coverage for specified medical services. Breach of the obligations set out in the Amendment Rules may result in penalties. Although the specific penalties are not detailed in the explanatory statement, it is generally understood that non-compliance with private health insurance regulations can lead to enforcement actions by the relevant authorities, including fines and other administrative penalties. Additionally, insurers who fail to meet the minimum benefit requirements may face civil liability claims from policyholders who are underpaid for their treatments. It is important for insurers to maintain accurate records and ensure that their practices align with the updated Rules to avoid such consequences.

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