EXPLANATORY STATEMENT
Issued by the Authority of the Minister for Health
Private Health Insurance Act 2007
Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (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 2014 (No. 5) (the Amendment Rules) consist of one Schedule, which amend Schedules 1 and 3 of the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules), which commenced on 1 November 2011.
Purpose
Schedule A of the Amendment Rules
The purpose of Schedule A to the Amendment Rules is to amend Schedules 1 and 3 of the Principal Rules to insert 48 Medicare Benefits Schedule (MBS) item numbers and remove seven MBS item numbers. The updates reflect the changes made to the Health Insurance (General Medical Services Table) Regulations (GMST) the Health Insurance (Diagnostic Imaging Services Table) Regulations (DIST) and the Health Insurance (Pathology Services Table) Regulations (PST). The amendments to the GMST and the DIST commence on 1 November 2014 while some of the amendments to the PST take effect from
1 November 2014 and some from 1 January 2015.
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 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.
Details
Details of the Amendment Rules are set out in the Attachment.
Consultation
In accordance with changes to the MBS, 48 MBS item numbers have been added and seven MBS item numbers have been deleted from the Principal Rules. 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.
Items 1, 2, 4, 5, 6 and 7 of the Amendment Rules commence on 1 November 2014 while item 3 of the Amendment Rules commences on 1 January 2015.
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 2014
ATTACHMENT
DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2014 (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 2014 (No. 5) (the Amendment Rules).
Section 2 Commencement
Section 2 provides that items 1, 2, 4, 5, 6 and 7 of the Amendment Rules commence on
1 November 2014 while item 3 of the Amendment Rules commences on 1 January 2015.
Section 3 Authority
Section 3 provides that the Amendment 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.
Schedule A
Schedule A provide that 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 1, Part 2 Type A procedures, Clause 6 Surgical patient, subclause (3)
Item 1 amends Schedule 1, Part 2 Type A procedures, Clause 6 Surgical patient, subclause (3) of the Principal Rules by inserting MBS item number 35534.
Item number 35534 will clarify the clinical conditions for vulvoplasty in item 35533 by splitting it into two separate items (35533 and 35534) to better articulate the clinical conditions to which the service applies.
Item 2 – Schedule 3, Part 2 Type B procedures, Clause 5 Non-band specific Type B day procedures, subclause (1)
Item 2 amends Schedule 3, Part 2 Type B procedures, Clause 5 Non-band specific Type B day procedures, subclause (1) by inserting one new MBS item number (18379).
New item 18379 will be introduced for the intravesical injection of Botox® for the treatment of certain patients with urinary incontinence due to idiopathic overactive bladder.
This change will be effective from 1 November 2014 and subsequently needs to be inserted into the Principal Rules.
Item 3 – Schedule 3, Part 2 Type B procedures, Clause 5 Non-band specific Type B day procedures, subclause (1)
Item 3 amends Schedule 3, Part 2 Type B procedures, Clause 5 Non-band specific Type B day procedures, subclause (1) by inserting 27 new MBS item numbers.
Amendments are being made to the Health Insurance (Diagnostic Imaging Services Table) Regulations to implement the 2014-15 Budget measure, ‘MBS – revised capital sensitivity provisions for diagnostic imaging equipment’, which is to take effect on 1 January 2015, resulting in the addition of 27 new (NK) angiography items where corresponding (K) items are referenced. Subsequently these items are being inserted into the Principal Rules.
Item 4 – Schedule 3, Part 3, Type C procedures, Clause 8 Interpretation, Category 5 Diagnostic Imaging Services, I5
Item 4 amends Schedule 3, Part 3 Type C procedures, Clause 8 Interpretation, Category 5 Diagnostic Imaging Services, I5 of the Principal Rules by inserting six new MBS item numbers (63740, 63741, 63743, 63744, 63746 and 63747).
Amendments are being made to the DIST to insert six new MBS items (63740, 63741, 63743, 63744, 63746, and 63747) that will be listed for Magnetic Resonance Imaging for evaluation of pelvic sepsis and fistulising perianal Crohn disease and evaluation of known or suspected complications in small bowel Crohn disease. These changes will be effective from
1 November 2014. Subsequently the abovementioned items need to be inserted and removed from the Principal Rules.
Item 5 – Schedule 3, Part 3, Type C procedures, Clause 8 Interpretation, Category 3 Therapeutic Procedures, T11
Item 5 amends Schedule 3, Part 3 Type C procedures, Clause 8 Interpretation, Category 3 Therapeutic Procedures, T11 of the Principal Rules by removing two MBS item numbers (18356 and 18358).
Amendments are being made to fourteen items listed in the Health Insurance (General Medical Services Table) Regulations (GMST) to reflect a more simplified item structure. These amendments will result in the removal of items 18356 and 18358 from the GMST which subsequently require removal from the Principal Rules.
Item 6 – Schedule 3, Part 3 Type C procedures, Clause 8, Interpretation, Category 6 – Pathology services, P2
Item 6 amends Schedule 3, Part 3 Type C procedures, Clause 8, Interpretation, Category 6 – Pathology services, P2 of the Principal Rules by removing four MBS item numbers (66599, 66602, 66608 and 66609) and inserting nine new MBS item numbers (66833, 66834, 66835, 66836, 66837, 66838, 66839, 66840 and 66841).
Amendments are being made to the Health Insurance (Pathology Services Table) Regulations (PST) to insert eight new items to provide a more targeted approach to existing arrangements for Vitamin D, B12, and Folate, as recommended by the Medical Services Advisory Committee (MSAC). As a consequence, the current items for Vitamin D, B12, and Folate (66608, 66609, 66599, and 66602) will be removed from the PST. Further, a new item (66841) is also being listed in the PST for quantitation of HbA1c for the diagnosis of diabetes mellitus in patients with undiagnosed diabetes who are considered at high risk of the disease.
These changes will be effective from 1 November 2014. Subsequently the abovementioned items need to be inserted and removed from the Principal Rules.
Item 7 – Schedule 3, Part 3 Type C procedures, Clause 8, Interpretation, Category 6 – Pathology services, P7
Item 7 amends Schedule 3, Part 3 Type C procedures, Clause 8, Interpretation, Category 6 – Pathology services, P7 of the Principal Rules by removing one MBS item number (73328) and inserting four new MBS item numbers (73336, 73337, 73339 and 73340).
Amendments are being made to the PST to insert two current MBS items (73336 and 73337) to reflect current MBS pathology services. Subsequently item 73328 is being removed from the PST as it is made redundant by the inserted items.
Further amendments are being made to the PST to insert two new MBS items (73339 and 73340) to cover the use of diagnostic and predictive testing for mutations in the RET gene. These items would be for patients with symptoms of multiple endocrine neoplasia type II (MEN2) and unaffected relatives of a patient with a documented RET mutation to determine the risk of disease. Subsequently the abovementioned items need to be respectively inserted and removed from the Principal Rules.
These changes will be effective from 1 November 2014. Subsequently the abovementioned items need to be inserted and removed from the Principal Rules.