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. 8)
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. 8) (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 two new Medicare Benefits Schedule (MBS) item numbers as a result of changes to the Health Insurance (Optical Coherence Tomography) Determination 2016. Two existing MBS item numbers have been amended to rectify a clerical error whereby the numbers were added to an incorrect clause in the Principal Rules.
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 (Optical Coherence Tomography) Determination 2016, two new MBS item numbers have been added. Medical advice sought from within the Department confirmed that two existing MBS item numbers had been inserted in the incorrect clause. No further consultation was undertaken because the amendment is minor in nature and does not significantly affect existing arrangements.
The Amendment Rules commences on 1 December 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. 8)
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.8) (the Amendment Rules).
Section 2 Commencement
Section 2 provides that the Amendment Rules are to commence on 1 December 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 removing two MBS items numbers (45201 and 45202) due to a clerical error.
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 two MBS items numbers (45201 and 45202). The items are for the provision of services for surgical excision in the removal of malignant or non-malignant skin lesions.
Item 3 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 2, Diagnostic procedures and investigations, D1
Item 3 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 2, Diagnostic procedures and investigations, D1 of the Principal Rules by inserting two new MBS item numbers (11219 and 11220). MBS item 11219 for optical coherence tomography was amended to reflect the listing on the Pharmaceutical Benefits Scheme (PBS) of aflibercept to treat branch retinal vein occlusion and ocriplasmin to treat vitreomacular traction. Item 11220 has been listed for optical coherence tomography for the assessment of the need for further treatment following PBS-subsidised ocriplasmin.