Private Health Insurance (Benefit Requirements) Amendment Rules 2013 (No. 5)

Administered by Department of Health, Disability and Ageing

Legislation au F2013L01753 Rules Not in force Legislative Instrument

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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. 

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules 2013 (No. 5) were enacted under section 333-20 of the Private Health Insurance Act 2007 to address the need for updating the minimum benefit requirements for private health insurance. These rules aim to incorporate new Medicare Benefits Schedule (MBS) items and update the list of facilities eligible for second-tier default benefits. The rules were made by the Minister for Health and commenced on 1 October 2013. The primary purpose of these amendments is to ensure that private health insurers provide adequate benefits for certain medical procedures and to maintain the integrity of the second-tier default benefits system, which ensures that patients receive a minimum level of coverage for hospital treatments in the absence of negotiated agreements between insurers and hospitals. The changes were the result of consultations with the relevant industry stakeholders, particularly the Second Tier Advisory Committee, and were deemed necessary to reflect recent developments in medical services and facility approvals.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2013 (No. 5) amends the Private Health Insurance (Benefit Requirements) Rules 2011, which specify the minimum benefit requirements for certain hospital treatments under private health insurance. These amendment rules apply to private health insurers operating in Australia, specifically to the benefit requirements for hospital treatments outlined in Schedules 3 and 5 of the Principal Rules. Schedule 3 pertains to same day hospital accommodation benefits, while Schedule 5 relates to second-tier default benefits, which are applicable when a health insurer does not have a negotiated agreement with a hospital. The amendments to Schedule 3 include the addition of a new Medicare Benefits Schedule (MBS) item number (18375) for the injection of botulinum toxin to treat urinary incontinence caused by neurogenic detrusor overactivity, effective from 1 October 2013. Similarly, the amendments to Schedule 5 update the list of facilities eligible for second-tier default benefits based on the latest approval by the Second Tier Advisory Committee. These rules apply nationally across Australia and were made under the authority provided by section 333-20 of the Private Health Insurance Act 2007.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules 2013 (No. 5) (the Amendment Rules) introduce several key changes to the existing Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules). The Amendment Rules, under Section 333-20 of the Private Health Insurance Act 2007, modify Schedules 3 and 5 of the Principal Rules. These amendments aim to incorporate new Medicare Benefits Schedule (MBS) item numbers and update the list of facilities eligible for second-tier default benefits. The Amendment Rules impose specific obligations on health insurers, primarily concerning the payment of benefits for certain medical procedures and the inclusion of facilities in the second-tier benefit list. Health insurers are required to recognise new MBS item 18375 for botulinum toxin injections to treat urinary incontinence due to neurogenic detrusor overactivity as a same-day hospital procedure, as outlined in Schedule A. In Schedule B, insurers must refer to the updated list of facilities approved by the Second Tier Advisory Committee for eligibility in second-tier default benefits. These changes ensure that health insurers comply with the updated benefit requirements set forth by the Act. Failure to comply with the provisions of the Amendment Rules can result in legal consequences for health insurers. While the Amendment Rules do not explicitly state penalties for non-compliance, breaches of the Private Health Insurance Act 2007 can lead to enforcement actions by the Australian Prudential Regulation Authority (APRA). Potential consequences include fines, corrective actions, or more severe penalties if the breach is deemed significant. Additionally, health insurers may face civil liabilities for failing to provide the required benefits, potentially leading to claims from policyholders. The Amendment Rules are designed to ensure that health insurers adhere to updated benefit requirements for specific medical procedures and facilities. By amending Schedules 3 and 5 of the Principal Rules, the Amendment Rules aim to enhance the clarity and comprehensiveness of benefit provisions under the Private Health Insurance Act 2007. Health insurers must stay informed about these changes to avoid potential legal and financial repercussions.

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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.