I ddEXPLANATORY STATEMENT
Issued by the Authority of the Minister for Health
Private Health Insurance Act 2007
Private Health Insurance (Benefit Requirements) Amendment Rules 2015 (No. 6)
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. 6) (the Amendment Rules) consist of the Schedule – Amendments, which amends Schedules 1, 3 and 5 of the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.
Purpose
The purpose of the amendments to Schedules 1 and 3 of the Principal Rules is insert eight new Medicare Benefits Schedule (MBS) item numbers. The purpose of the amendment to Schedule 5 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 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.
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), seven MBS item numbers have been added. One item has been added to the Pathology Services Table (PST). 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.
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 1 January 2016.
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
21 DECEMBER 2015
Attachment
DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2015 (No.6)
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.6) (the Amendment Rules).
Section 2 Commencement
Section 2 provides that the Amendment Rules are to commence on 1 January 2016.
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 – Amendments
The Schedule – Amendments 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 1 amends Schedule 1, Part 2 – Type A Procedures, Clause 4 Advanced surgical Patient, Subclause (3) of the Principal Rules by inserting two new MBS items numbers (30176 and 30179).
MBS items 30176 and 30179 are new Lipectomy surgical items.
Item 2 - Schedule 1, Part 2 – Type A Procedures, Clause 6 Surgical patient, Subclause (3)
Item 2 amends Schedule 1, Part 2 – Type A Procedures, Clause 6 Surgical patient, Subclause (3) of the Principal Rules by inserting one new MBS item number (30172) and deleting one item (30174). MBS item 30172 is a new Lipectomy surgical item.
Item 3 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 3 – Therapeutic procedures, T2
Item 3 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 3 – Therapeutic procedures, T2 of the Principal Rules by inserting four new MBS item numbers (15275, 15555, 15565 and 15715). MBS items 15275, 15555, 15565 and 15715 are all new MBS items for the treatment of various forms of cancer.
Item 4 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 6 – Pathology services, P7
Item 4 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 6 – Pathology services, P7 of the Principal Rules by inserting one new MBS item number (73342) in the pathology services table. Item 73342 is a new item for in-situ hybridisation test of tumour tissue from a patient to determine eligibility to access trastuzumab (for treatment of gastric cancer) under the Pharmaceutical Benefits Scheme.
Item 5 - Schedule 5, Clause 4 Facilities, subclause (1)
Item 5 amends Schedule 5, Clause 4 Facilities, subclause (1) of the Principal Rules by updating 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’s website at http://www.health.gov.au/.