Private Health Insurance (Benefit Requirements) Amendment Rules 2016 (No. 7)

Administered by Department of Health, Disability and Ageing

Legislation au F2016L01665 Rules Not in force Legislative Instrument

Legislation content

EXPLANATORY STATEMENT

 

Issued by the Authority of the Minister for Health

 

Private Health Insurance Act 2007

 

Private Health Insurance (Benefit Requirements) Amendment Rules 2016 (No. 7)

 

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 2016 (No. 7) (the Amendment Rules) consist of amendments 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

The purpose of the Schedule to the Amendment Rules is to amend Schedule 1 and Schedule 3 of the Principal Rules to insert 70 new Medicare Benefits Schedule (MBS) item numbers and remove 54 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 Legislation Amendment (2016 Measures No. 2) Regulation 2016, 70 new MBS item numbers have been added and 54 MBS item numbers have been removed.  Medical advice was sought from within the Department regarding this amendment. No further consultation was undertaken because the amendment is minor in nature and does not significantly affect existing arrangements.

 

The Amendment Rules commence on 1 November 2016.

 

The Amendment Rules are a legislative instrument for the purposes of the
Legislation Act 2003.

 


Attachment

 
DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2016 (No. 7)

 

Section 1 Name of Rules

 

Section 1 provides that the title of the Rules is the
Private Health Insurance (Benefit Requirements) Amendment Rules 2016 (No.7) (the Amendment Rules).

 

Section 2 Commencement

 

Section 2 provides that the Amendment Rules are to commence on 1 November 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

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 (45201 and 45202).

 

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) of the Principal Rules by inserting 16 new MBS item numbers (30658, 31356, 31358, 31359, 31360, 31361, 31363, 31364, 31367, 31369, 31371, 31372, 31373, 31374, 31375 and 31376) and deleting 48 items (30653, 30656, 30659, 30660, 31230, 31235, 31240, 31255, 31256, 31257, 31258, 31260, 31261, 31262, 31263, 31265, 31266, 31267, 31268, 31270, 31271, 31272, 31273, 31275, 31276, 31277, 31278, 31280, 31281, 31282, 31283, 31285, 31286, 31287, 31288, 31290, 31291, 31292, 31293, 31295, 31300, 31305, 31310, 31315, 31320, 31325, 31330, and 31335).

 

 

 

 

Item 3 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 1, Attendance, Subclause (A26)

 

Item 3 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 1, Attendance, Subclause (A26) of the Principal Rules by inserting 31 new MBS item numbers (6018, 6019, 6023, 6024, 6025, 6026, 6028, 6029, 6031, 6032, 6034, 6035, 6037, 6038, 6042, 6051, 6052, 6057, 6058, 6059, 6060, 6062, 6063, 6064, 6065, 6067, 6068, 6071, 6072, 6074 and 6075).

 

Item 4 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 2, Diagnostic procedures and investigations, Subclause (D1)

 

Item 4 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 2, Diagnostic procedures and investigations, Subclause (D1) of the Principal Rules by inserting five new MBS item numbers (12017, 12022, 12024, 12325 and 12326) and deleting two MBS item numbers (12015 and 12018).

 

Item 5 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 3, Therapeutic procedures, Subclause (T8)

 

Item 5 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 3, Therapeutic procedures, Subclause (T8) of the Principal Rules by inserting 12 new MBS item numbers (30072, 30654, 31206, 31211, 31216, 31221, 31357, 31362, 31365, 31366, 31368 and 31370) and deleting four MBS item numbers (31200, 31205, 31210 and 31215).

 

Item 6 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 5, Diagnostic Imaging Services, Subclause (I5)

 

Item 6 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 5, Diagnostic Imaging Services, Subclause (I5) of the Principal Rules by inserting four new MBS item numbers (63487, 63488, 63489 and 63490).

 

 

These new items included in the General Medical Services Table were registered on the Federal Register of Legislation on 14 October 2016.

 


 

 

 

 

 

 

 

 

 

 

 

 

 

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules 2016 (No. 7) were enacted by the Australian Government to amend the Private Health Insurance (Benefit Requirements) Rules 2011, addressing the need for updating the Medicare Benefits Schedule (MBS) items under the Private Health Insurance Act 2007. This amendment was introduced to ensure that the benefit requirements for hospital treatments are kept current and relevant, thereby maintaining the integrity and efficacy of the private health insurance system. The rules were made under the authority of Section 333-20 of the Private Health Insurance Act 2007, empowering the Minister for Health to make such amendments as necessary. The policy objective is to ensure that the minimum benefit requirements for private health insurance are in line with current medical practices and technological advancements, ultimately enhancing the coverage and accessibility of healthcare services for insured individuals. The Amendment Rules consist of modifications to Schedules 1 and 3 of the Principal Rules, incorporating 70 new MBS item numbers while removing 54 existing ones. This update ensures that the benefit requirements reflect the latest medical services and procedures, thereby providing better coverage and support for patients under private health insurance. These changes are intended to maintain the relevance and effectiveness of the benefit requirements, ensuring that they align with contemporary healthcare practices and advancements. The Amendment Rules were gazetted and came into effect on 1 November 2016.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2016 (No. 7) are subordinate legislation made under the authority of section 333-20 of the Private Health Insurance Act 2007, which allows the Minister for Health to make rules concerning the minimum benefits required for private health insurance. These Amendment Rules specifically modify Schedules 1 and 3 of the Private Health Insurance (Benefit Requirements) Rules 2011, which set out the minimum levels of benefit payable for various types of hospital treatment. The Amendment Rules apply nationally, affecting all private health insurers operating in Australia. They amend the lists of Medicare Benefits Schedule (MBS) item numbers for different categories of hospital treatment, including adding 70 new MBS item numbers and removing 54 existing ones. These changes are effective from 1 November 2016 and do not significantly alter existing arrangements, as determined by the Department's internal medical consultation process. The Amendment Rules thus provide a mechanism to update and refine the scope of private health insurance benefits in line with current medical practices and services.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules 2016 (No. 7) primarily serve to update and refine the minimum benefit requirements for private health insurance in Australia by amending Schedules 1 and 3 of the Private Health Insurance (Benefit Requirements) Rules 2011. Section 1 identifies the name of these Amendment Rules, while Section 2 establishes that they will commence on 1 November 2016. Section 3 clarifies that these Rules are made under item 3A of the table in section 333-20 of the Private Health Insurance Act 2007. The Amendment Rules impose specific obligations on health insurers regarding the minimum levels of benefits that must be provided to patients. These obligations are detailed in the Schedules of the Amendment Rules, which amend Schedules 1 and 3 of the Principal Rules. For instance, Schedule 1, which pertains to overnight patient classifications such as 'Advanced surgical patient', 'Obstetric patient', 'Surgical patient', 'Psychiatric patient', 'Rehabilitation patient', and 'Other patients', has been updated to include new Medicare Benefits Schedule (MBS) item numbers and remove others. Similarly, Schedule 3, which deals with same day hospital accommodation benefits, has been amended to include new MBS item numbers and remove existing ones. These amendments ensure that the minimum benefit requirements for hospital treatment remain current and reflective of the latest medical services and procedures. Failure to comply with the obligations outlined in these Amendment Rules can lead to significant consequences for health insurers. Although the Explanatory Statement does not explicitly mention offences, penalties, or consequences for breach, it is reasonable to infer that non-compliance with the stipulated benefit requirements could result in legal action or regulatory penalties. Health insurers that fail to adhere to the updated minimum benefit requirements may be subject to enforcement actions by the relevant regulatory bodies, potentially including fines or other sanctions. These consequences underscore the importance of compliance with the provisions of the Amendment Rules to ensure that patients receive the appropriate level of coverage and benefits under their private health insurance policies. In summary, the Private Health Insurance (Benefit Requirements) Amendment Rules 2016 (No. 7) make specific amendments to the minimum benefit requirements for hospital treatment in private health insurance. These changes involve updating the MBS item numbers in Schedules 1 and 3 of the Principal Rules. Health insurers are obligated to comply with these updated requirements to ensure they provide the mandated levels of benefits to their policyholders. While the Explanatory Statement does not detail specific penalties for non-compliance, it is clear that failure to meet the updated benefit requirements could result in significant consequences for health insurers.

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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.