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. 5)
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. 5) (the Amendment Rules) amend Schedules 3 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
The purpose of the amendment to Schedule 3 of the Principal Rules is to add one new Medicare Benefits Schedule (MBS) item number.
Schedule B of the Amendment Rules
The purpose of the amendment 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 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 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 Amendments
MBS item 18375 will commence on 1 October 2013 under the Health Insurance (Botulinum Toxin for Urinary Incontinence due to Neurogenic Detrusor Overactivity) Determination 2013 (the Determination) made under section 3C of the Health Insurance Act 1973. MBS item 18375 is a new item for injection of botulinum toxin to treat urinary incontinence caused by neurogenic detrusor overactivity. Medical advice was sought from within the Department regarding these amendments. No further consultation was undertaken because the amendments are minor in nature and do not significantly affect existing arrangements, and broader consultation was undertaken by the Department in relation to the item as part of the Determination.
Schedule B Amendments
Consultation for changes to Schedule 5 occurred with industry through the Second Tier Advisory Committee (the Committee), which includes 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 1 October 2013 or, if registered after 1 October 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
MEDICAL BENEFITS DIVISION
DEPARTMENT OF HEALTH
OCTOBER 2013
ATTACHMENT
DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2013 (No. 5)
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. 5) (the Amendment Rules).
Section 2 Commencement
Section 2 provides that the Amendment Rules are to commence on 1 October 2013 or, if registered on a later date, the day after registration.
Section 3 Authority
These rules are made under item 3A of the table in section 333-20 of the Private Health Insurance Act 2007.
Section 4 Schedule
Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.
Schedules A and B
Schedules A and B provide that Schedules 3 and 5 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 3, Part 2 - Type B procedures, Clause 5 - Non-band specific Type B day procedures, subclause (1)
Patients are taken to be same day patients if they meet the criteria of Schedule 3, Part 1, subclause 1(a)(b) and (c) of the Principal Rules. Schedule 3, Part 1, subclause 5 of the Principal Rules sets out the MBS item numbers for the purposes of this clause.
Item 1 amends Schedule 3, Part 1, subclause 5 by inserting one new MBS item (18375) into Schedule 3 of the Principal Rules to reflect that they should be classified as same day procedures.
MBS item 18375 was created under a 3C Determination, which commences on 1 October 2013. MBS item 18375 is a new item for injection of botulinum toxin to treat urinary incontinence caused by neurogenic detrusor overactivity.
Schedule B – Amendments
Item 1 – Schedule 5, Clause 4 - Facilities, subclause (1)
Item 1 of Schedule B to the Amendment Rules updates the reference to the latest Second Tier Advisory Committee-approved list. A hospital is a facility for the purposes of this Schedule if it is included in the list of second-tier eligible facilities approved by the Second Tier Advisory Committee existing at the time that the Private Health Insurance (Benefit Requirements) Amendment Rules 2013 (No. 5) commence.