EXPLANATORY STATEMENT
Issued by the Authority of the Minister for Health
Private Health Insurance Act 2007
Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (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 2015 (No. 3) (the Amendment Rules) consist of four Schedules (A, B, C and D), which amend Schedules 1-5 of the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.
Purpose
The purpose of the Schedule to the Amendment Rules is to amend Schedules 1 and 3 of the Principal Rules to insert 51 Medicare Benefits Schedule (MBS) item numbers and remove three MBS item numbers.
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.
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.
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
In accordance with changes to the Health Insurance (General Medical Services Table) Regulations (GMST), 48 MBS item numbers have been added and three MBS item numbers have been deleted. One item has been added to the Pathology Services Table (PST) and two items have been added to the Diagnostic Imaging Services Table. 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.
The Amendment Rules commence on 1 September 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
AUGUST 2015
DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2015 (No. 3)
Section 1 Name of Rules
Section 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 3) (the Amendment Rules).
Section 2 Commencement
Section 2 provides that the Amendment Rules are to commence on 1 September 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.
Schedules A, B, C and D
Schedules A, B, C and D provide that 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 1, Part 2 – Type A Procedures, Clause 4, Advanced surgical patient, Subclause (3)
Item 2 amends Schedule 1, Part 2 – Type A Procedures, Clause 4, Advanced surgical patient, Subclause (3) of the Principle Rules by inserting three new MBS item numbers (31516, 43838 and 37825).
MBS item 31515 is a new item for the treatment of early stage breast cancer using targeted intraoperative radiotherapy. MBS items 43838 and 37825 are new paediatric surgery items.
These three items will be included in the GMST from 1 September, 2015.
Item 2 – Schedule 1, Part 2 – Type A Procedures, Clause 6 Surgical patient, Subclause (3)
Item 3 amends Schedule 1, Part 2 – Type A Procedures, Clause 6 Surgical patient, Subclause (3) of the Principle Rules by deleting three MBS item numbers (30612, 30616 and 30617) and inserting 30 new MBS item numbers (30287, 30326, 30608, 30611, 30618, 30619, 30622, 30623, 30626, 30637, 30639, 30643, 30645, 30646, 34529, 34534, 37801, 37804, 37807, 37810, 37813, 37819, 37822, 37828, 37834, 43805, 43832, 43835, 43841, 44101).
The introduction of new items has resulted in the redundancy and subsequent deletion of items 30612, 30616 and 30617.
The 30 new items have been introduced as part of a revised listing for paediatric surgical services. These new items will be included in the GMST from 1 September, 2015.
Item 3 – Schedule 3, Part 2 – Type B Procedures, Clause 4, Band 1, Subclause (1)
Item 1 amends Schedule 3, Part 2 – Type B Procedures, Clause 4, Band 1, Subclause (1) of the Principle Rules by inserting paragraph (c) Category 2 – Diagnostic procedures and investigations, being the item below in the general medical services table and group D1: Miscellaneous diagnostic procedures and investigation, which includes one new MBS item number (11801). This item has been added as an equivalent item for endoscopy and will be included in the GMST from 1 September 2015.
Item 4 – Schedule 3, Part 2 – Type B Procedures, Clause 5, Non-band specific Type B day procedures, Subclause (1)
Item 4 amends Schedule 3, Part 2 – Type B Procedures, Clause 5 Non-band specific Type B day procedures, Subclause (1) by inserting five new MBS item numbers (30105, 30627, 37816, 42576 and 44104)
The five new items have been introduced as part of a revised listing for paediatric surgical services. These new items will be included in the GMST from 1 September, 2015.
Item 5 – Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 1 - Attendances
Item 5 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 1 – Attendances by inserting a new group A10, which includes five new MBS items (10944, 10945, 10946, 10947 and 10948).
Item 10944 is a new item for the removal of superficial embedded corneal foreign bodies by an optometrist.
Items 1094, 10946, 10947 and 10948 are new items for optometrists to provide clinical support to a patient during telehealth consultations with ophthalmologists.
These new items will be included in the GMST from 1 September, 2015.
Item 6 – Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 2 – Diagnostic procedures & investigations, D1
Item 6 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 2 – Diagnostic procedures & investigations, D1 by inserting four new MBS item numbers (11719, 11720, 11725 and 11726)
These new items are being introduced to enable remote monitoring of implanted cardiac devices.
These new items will be included in the GMST from 1 September, 2015.
Item 7 – Schedule 3, part 3 – Type C Procedures, Clause 8 Interpretation, Category 5 – Diagnostic Imaging Services, I2
Item 7 amends Schedule 3, part 3 – Type C Procedures, Clause 8 Interpretation, Category 5 – Diagnostic Imaging Services, I2 by deleting two MBS item numbers (56552 and 56554) and inserting two new MBS item numbers (56553 and 56555).
These two new items are for computed tomography colonography. The introduction of new items has resulted in the redundancy and subsequent deletion of items 56552 and 56554.
These new items will be included in the Diagnostic Imaging Services Table from 1 September, 2015.
Item 8 – Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 6 – Pathology services, P7
Item 8 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 6 – Pathology services, P7 by inserting one new MBS item number 73338.
This new item will be inserted into the PST for pharmacogenetic testing – RAS (KRAS and NRAS) Determination.
This new item will be included in the Pathology Services Table from 1 September, 2015.