EXPLANATORY STATEMENT
Issued by the Authority of the Minister for Health
Private Health Insurance Act 2007
Private Health Insurance (Benefit Requirements) Amendment Rules 2013 (No. 1)
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 2013 (No. 1) (the Amendment Rules) amend Schedules 1, 3, 4 and 5 of the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.
Purpose
Schedule A of the Amendments Rules
Schedule A of the Amendment Rules amends Schedule 4 of the Principal Rules. The purpose of the amendments to Schedule 4 of the Principal Rules is to change the minimum benefits payable by private health insurers per night for nursing-home type patients (NHTPs) at public hospitals in some States and Territories and at private hospitals nationally.
Schedule B of the Amendment Rules
Schedule B of the Amendment Rules amends Schedules 1 and 3 of the Principal Rules. The purpose of the amendments to Schedules 1 and 3 of the Principal Rules is to add three new Medicare Benefits Schedule (MBS) item numbers.
Schedule C of the Amendment Rules
The purpose of the amendments to Schedule 5 of the Principal Rules is to update the reference to the new Second Tier Advisory Committee (the Committee) approved list of facilities that are eligible for second-tier default benefits.
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 benefits 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 1 categorises MBS item numbers into overnight patient classifications comprising ‘Advanced surgical patient’, ‘Obstetric patient’, ‘Surgical patient’, ‘Psychiatric patient’, ‘Rehabilitation patient’ and ‘Other patients’. 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.
The minimum benefits payable per night for hospital treatment provided to NHTPs in Schedule 4 of the Principal Rules is subject to review and change twice annually, to reflect the indexation applied to the Adult Pension Basic Rate and Maximum Daily Rate of Rental Assistance (Pension and Rental Assistance Rates). The latest indexation of these rates becomes effective on 20 March 2013.
Schedule 5 of the Principal Rules requires a health insurer to pay second tier default benefits for most episodes of hospital treatment provided in private hospital facilities that are specified in Schedule 5 if the health insurer does not have a negotiated agreement with the hospital. Schedule 5 sets a higher minimum level of benefit (for overnight treatment and day only treatment provided in specified facilities) than the minimum benefit set for such treatment by Schedules 1, 2 and 3 of the Principal Rules.
Details
Details of the Amendment Rules are set out in the Attachment.
Consultation
Schedule A of the Amendment Rules - Items 1 and 2
On 25 February 2013, States and Territories were asked whether they would be increasing the NHTP contribution and accommodation rates in their jurisdiction in line with increases in the Pension and Rental Assistance Rates. New South Wales, Queensland, South Australia, Victoria and Tasmania advised that they will increase the NHTP contribution rates in their public hospitals from 20 March 2013. The Australian Capital Territory advised that it is not increasing its NHTP contribution and accommodation rates at this time. Western Australia advised of their intention to increase NHTP contribution rates at a later date yet to be determined. No advice was received from Northern Territory.
No specific consultation was undertaken in relation to Schedule A, item 2 of the Amendment Rules regarding private hospitals because the change was machinery in nature and linked to the twice annual Pension and Rental Assistance Rates increase. The change does not substantially alter existing arrangements.
Schedule B of the Amendment Rules
Three new MBS item numbers were added. Medical advice was sought from within the Department about the addition of the MBS item numbers. No further consultation was undertaken because the amendments are minor in nature.
Schedule C of the Amendment Rules
Consultation for changes to Schedule 5 occurred with industry through the Committee, which includes equal representation from both private hospital and private health insurance sectors. Facilities wishing to be considered for inclusion in Schedule 5 were individually assessed and decided by the Committee.
The Amendment Rules commence on 20 March 2013 or, if registered after 20 March 2013, 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
PRIVATE HEALTH INSURANCE BRANCH
DEPARTMENT OF HEALTH AND AGEING
MARCH 2013
ATTACHMENT
Details of the Private Health Insurance (Benefit Requirements) Amendment Rules 2013 (No. 1)
Section 1 Name of Rules
Section 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2013 (No. 1) (the Amendment Rules).
Section 2 Commencement
Section 2 provides that the Amendment Rules are to commence on 20 March 2013 or, if registered on a later date, the day after registration.
Section 3 Amendment of Private Health Insurance (Benefit Requirements) Rules 2011
Section 3 provides that Schedules A, B and C to the Amendment Rules amend the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.
Schedule A – Amendments
Item 1 – Schedule 4, Clause 6 Minimum benefit, Table 1
Item 1 of Schedule A to the Amendment Rules increases the minimum benefit payable per night for nursing-home type patients in public hospitals in the following States in clause 6, Table 1:
- New South Wales from $109.10 to $111.70;
- Tasmania from $124.90 to $128.50.
- Queensland from $102.00 to $105.50
Item 2 – Schedule 4, Clause 6 Minimum benefit, Table 2
Item 4 of Schedule A to the Amendment Rules decreases the minimum benefit payable per night for nursing-home type patients in private hospitals in clause 6, Table 2:
- Private hospitals from $59.05 to $57.55
Schedule B – Amendments
Item 1 - Schedule 1, Part 2 Type A procedures, Clause 6 Surgical Patient, subclause (3)
Patients are taken to be surgical type overnight patients if they meet the criteria of Schedule 1, Part 2, subclause 6(2) and are receiving the items listed in subclause 6(3), within the fee range of $254.00 to $852.95. Subclause 6(3) of the Principal Rules sets out the MBS item numbers for the purposes of this clause of the Principal Rules, but indicates that a listing in subclause 6(3) only applies where an item has a fee in the MBS within the specified range.
Item 1 amends Schedule 1, Part 2 Type A procedures, Clause 6 Surgical Patient, subclause (3) by inserting two MBS item numbers (32023 and 37245) into Schedule 1 of the Principal Rules to reflect that they should be classified as overnight hospital procedures.
Item 2 – Schedule 3, Part 3 Type C procedures, Clause 8 Interpretation, Category 2 Diagnostic Procedures & Investigations, D1
Item 2 amends Schedule 3, Part 3 Type C procedures, Clause 8 Interpretation, Category 2 Diagnostic Procedures & Investigations, D1 of the Principal Rules by inserting 1 MBS item (11244). This MBS item relates to diagnostic procedures and investigations which are not usually performed in hospital. However, it is recognised that this item may be performed, in rare cases, in isolation in hospital if determined by the treating medical practitioner.
Schedule C - Amendments
Item 1 – Schedule 5, Clause 4 Facilities, Paragraph (1)
Item 1 of Schedule C to the Amendment Rules updates the reference to the latest Second Tier Advisory Committee-approved list. The list of facilities eligible for second tier default benefits is the list existing at the time of this amendment and is published on the Department of Health and Ageing’s website at http://www.health.gov.au/