Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 3)

Administered by Department of Health, Disability and Ageing

Legislation au F2012L00905 Rules Not in force Legislative Instrument

Legislation content

 

EXPLANATORY STATEMENT

 

Issued by the Authority of the Minister for Health

 

Private Health Insurance Act 2007

 

Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 3)

 

Authority

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) Amendment Rules 2012 (No. 3) (the Amendment Rules) amends Schedules 3 of the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.

 

Purpose

The Amendment Rules amends Schedule 3 of the Principal Rules to reclassify Medicare Benefit Schedule (MBS) item number 42738, an ophthalmology item, in Schedule 3, Part 2 which is currently listed in Part 3 of Schedule 3 of the Principal Rules. 

 

In Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No.1) MBS item 42738 was moved from Schedule 3, Part 2 to Schedule 3, Part 3. It has subsequently been brought to the Department of Health and Ageing’s attention that moving MBS item 42738 from Part 2 to Part 3 may inadvertently, and negatively, affect patients.  The Department has decided to move MBS item 42738 back into Part 2, the case before Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No.1), and will conduct further consultation on the most appropriate location for MBS item number 42738 in the Principal Rules.

 

Background

The Principal Rules, which commenced on 1 November 2011, provide for the minimum benefit requirements for psychiatric, rehabilitation and palliative care and other hospital treatment.  Schedules 1 to 5 of the Principal 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).

 

Schedule 3 sets out MBS item numbers for the same day hospital accommodation benefits which are payable for privately insured patients in all states and territories. Schedule 3, Part 2, lists MBS items that normally require hospital treatment that does not include part of an overnight stay. Schedule 3, Part 3 lists MBS items numbers that normally do not require hospital treatment.

 

Private health insurers are required to pay a minimum same-day accommodation benefit, in respect of treatment covered under a private health insurance policy, for MBS items listed Schedule 3, Part 2 of the Principal Rules.  Insurers are only required to pay and accommodation benefit for MBS items listed in Schedule 3, Part 3 of the Principal Rules, in circumstances where a medical practitioner certifies that because of a medical condition of a patient, or because of special circumstances, it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at a hospital.

 

Details

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

 

Consultation

The Department of Health and Ageing has consulted with medical specialists regarding this amendment. The Amendment Rules are a result of these consultations.  The Department intends to consult further with medical practitioners, private health insurers and patients on the appropriate location of MBS item number 42738 in the Principal Rules.

 

The Amendment Rules commence on the day after registration.

 

The Amendment Rules are a legislative instrument for the purposes of the Legislative Instruments Act 2003.

Authority: Section 333-20 of the

Private Health Insurance Act 2007


ATTACHMENT

 

DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2012 (No. 3)

 

1.      Name of Rules

 

Section 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 3) (the Amendment Rules).

 

2.      Commencement

 

Section 2 provides that the Amendment Rules are to commence on the day after registration.

 

3.              Amendment of Private Health Insurance (Benefit Requirements) Rules 2011

 

Section 3 provides that the Schedule to the Amendment Rules amend the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.

 

Schedule Amendments

 

Item 1 – Schedule 3, Part 3, Subclause 8, Category 3 (T8)

 

Item 1 of the Schedule to the Amendment Rules deletes MBS item 42738 from Schedule 3, Part 3.

 

Item 2 – Schedule 3, Part 2, Subclause 5(1)

 

Item 2 of the Schedule to the Amendment Rules inserts MBS item 42738 in Schedule 3, Part 2 after item number 42692.

 

PRIVATE HEALTH INSURANCE BRANCH

DEPARTMENT OF HEALTH AND AGEING

APRIL 2012


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This material is provided to persons who have a role in Commonwealth legislation, policy and programs as general guidance only and is not to be relied upon as legal advice.  Commonwealth agencies subject to the Legal Services Directions 2005 requiring legal advice in relation to matters raised in connection with this template must seek that advice in accordance with the Directions.

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 3) were introduced to amend the Private Health Insurance (Benefit Requirements) Rules 2011, which set out the minimum benefit requirements for psychiatric, rehabilitation, palliative care, and other hospital treatments under the Private Health Insurance Act 2007. Enacted by the Parliament of Australia, the purpose of these rules was to address an inadvertent negative impact on patients caused by the reclassification of Medicare Benefit Schedule (MBS) item number 42738 from Part 2 to Part 3 in a previous amendment. The Department of Health and Ageing identified this issue and decided to revert MBS item 42738 back to its original classification in Part 2 of Schedule 3, pending further consultations with relevant stakeholders to determine its most appropriate location within the rules. This adjustment aims to ensure that patients receive the intended benefits without any unintended adverse effects. The rules were developed following consultations with medical specialists and are set to commence on the day after registration. The Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 3) provide for the reclassification of MBS item 42738, ensuring that private health insurers pay the necessary same-day accommodation benefits for this particular ophthalmology item, aligning with the original intent of the Private Health Insurance Act 2007 and its subsequent rules.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 3) amends the Private Health Insurance (Benefit Requirements) Rules 2011, which commenced on 1 November 2011, by reclassifying Medicare Benefit Schedule (MBS) item number 42738, an ophthalmology item, from Schedule 3, Part 3 back to Schedule 3, Part 2. This amendment is in response to concerns raised about the potential negative impact on patients due to the initial relocation of MBS item 42738. The Department of Health and Ageing has consulted with medical specialists and intends to further consult with medical practitioners, private health insurers and patients to determine the most appropriate location for MBS item number 42738 in the Principal Rules. The amendment rules apply to all private health insurers in Australia and are intended to ensure that they pay the minimum same-day accommodation benefit for MBS items listed in Schedule 3, Part 2 of the Principal Rules, unless a medical practitioner certifies that hospital treatment is necessary.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 3) amends the Private Health Insurance (Benefit Requirements) Rules 2011, which set out the minimum benefit requirements for psychiatric, rehabilitation, and palliative care, among other hospital treatments. Specifically, these Amendment Rules reclassify Medicare Benefit Schedule (MBS) item number 42738, an ophthalmology item, back to Schedule 3, Part 2. This change follows a previous amendment, the Private Health Insurance (Benefit Requirements) Amendment Rules 2012 (No. 1), which had moved the same item to Schedule 3, Part 3. The reclassification aims to address concerns that the previous placement may have negatively affected patients, and the Department of Health and Ageing will conduct further consultations to determine the most appropriate placement for MBS item 42738. The Amendment Rules impose obligations on private health insurers to pay a minimum same-day accommodation benefit for MBS items listed in Schedule 3, Part 2 of the Principal Rules. This means that for treatments covered under a private health insurance policy, insurers are required to provide benefits for certain hospital treatments that do not include part of an overnight stay. Conversely, for MBS items listed in Schedule 3, Part 3, insurers are only required to pay an accommodation benefit if a medical practitioner certifies that it would be contrary to accepted medical practice to provide the procedure without hospital treatment due to a medical condition or special circumstances. The Amendment Rules do not explicitly outline specific offences, penalties, or consequences for breach. However, the underlying Private Health Insurance Act 2007, which governs these Rules, does provide for a range of potential penalties for non-compliance with benefit requirements. These can include fines, corrective notices, and in severe cases, cancellation or suspension of an insurer's authority to provide private health insurance. The exact penalties would depend on the nature and severity of the breach, as outlined in the broader legislative framework.

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Sourced from the Federal Register of Legislation at 26 August 2026. For the latest information on Australian Government law please go to https://www.legislation.gov.au.