Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 1)

Administered by Department of Health, Disability and Ageing

Legislation au F2017L00084 Rules Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Issued by the Authority of the Minister for Health

 

Private Health Insurance Act 2007

 

Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 1)

 

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 2017 (No. 1) (the Amendment Rules) consist of amendments which amend Schedule 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 3 of the Principal Rules to insert two new Medicare Benefits Schedule (MBS) item numbers as a result of changes to the Health Insurance (ALK Gene Testing) Determination 2017 and the

Health Insurance (BRCA Gene Testing) Determination 2017.

 

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 (ALK Gene Testing) Determination 2017 and the Health Insurance (BRCA Gene Testing) Determination 2017, two new MBS item numbers have been added. This change was recommended by the Medical Services Advisory Committee (MSAC) at its meeting in November 2016. 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 February 2017.

 

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 2017 (No. 1)

 

Section 1 Name of Rules

 

Section 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No.1) (the Amendment Rules).

 

Section 2 Commencement

 

Section 2 provides that the Amendment Rules are to commence on 1 February 2017.

 

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 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 6, Pathology services, P7

Item 1 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 6, Pathology services, P7 of the Principal Rules by inserting two new Medicare Benefits Schedule (MBS) item numbers (73295 and 73341).

 

MBS item 73295 is a new Medicare pathology service that provides a rebate to patients for the detection of germline BRCA1 and BRCA2 mutation in selected patients with relapsed ovarian cancer with continued sensitivity to platinum-based chemotherapy, to inform eligibility for olaparib under the Pharmaceutical Benefits Schedule (PBS).  This item is a predictive test that will identify a sub-group of patients likely to benefit from olaparib treatment. 

 

MBS item 73341 reflects the listing on the PBS of ceritinib to treat locally advanced or metastatic non-small cell lung cancer (NSCLC).  Item 73341 funds a fluorescence in situ hybridisation test for patients with NSCLC.

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 1) were enacted to amend the Private Health Insurance (Benefit Requirements) Rules 2011, reflecting the changes made by the Health Insurance (ALK Gene Testing) Determination 2017 and the Health Insurance (BRCA Gene Testing) Determination 2017. These rules were made under the authority of section 333-20 of the Private Health Insurance Act 2007, which allows the Minister for Health to make rules providing for matters required or permitted by Part 3-3 of the Act. The amendment introduces two new Medicare Benefits Schedule (MBS) item numbers, 73295 and 73341, into Schedule 3 of the Principal Rules, which pertain to same day hospital accommodation benefits. This change was recommended by the Medical Services Advisory Committee (MSAC) in November 2016 and deemed minor, thus not warranting further consultation. The Amendment Rules commenced on 1 February 2017 and are considered a legislative instrument for the purposes of the Legislation Act 2003.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 1) amends the Private Health Insurance (Benefit Requirements) Rules 2011, which set out the minimum levels of benefit payable for various types of hospital treatment under private health insurance. This amendment applies to all private health insurers in Australia, ensuring that they provide appropriate benefits for specified medical procedures. The changes introduced by the Amendment Rules are a direct response to modifications in the Health Insurance (ALK Gene Testing) Determination 2017 and the Health Insurance (BRCA Gene Testing) Determination 2017, which were recommended by the Medical Services Advisory Committee. The Amendment Rules insert two new Medicare Benefits Schedule (MBS) item numbers into Schedule 3 of the Principal Rules, specifically for predictive BRCA gene testing in ovarian cancer patients and fluorescence in situ hybridisation testing for non-small cell lung cancer. These amendments aim to ensure that private health insurers cover these new medical services, thereby aligning private health benefits with contemporary medical practices and pharmaceutical developments. The rules are applicable nationally across all states and territories, and they came into effect on 1 February 2017.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 1) primarily amend Schedule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011, which sets out the minimum benefits for same day hospital accommodation. Specifically, these Amendment Rules (section 4) introduce two new Medicare Benefits Schedule (MBS) item numbers (73295 and 73341) into the Principal Rules. MBS item 73295 is a new pathology service that provides a rebate for the detection of germline BRCA1 and BRCA2 mutations in selected patients with relapsed ovarian cancer, which is crucial for determining eligibility for olaparib under the Pharmaceutical Benefits Schedule (PBS). Meanwhile, MBS item 73341 funds a fluorescence in situ hybridisation test for patients with locally advanced or metastatic non-small cell lung cancer (NSCLC), reflecting the listing of ceritinib on the PBS. The Amendment Rules impose specific obligations on health insurers and health practitioners. Health insurers must adhere to the new MBS item numbers by providing the stipulated rebates for the specified pathology services when the conditions for the tests are met. Health practitioners must ensure that they bill according to the new MBS items when providing these services to eligible patients. This requirement ensures that patients receive the appropriate benefits under their private health insurance for these critical tests. Failure to comply with the provisions of these Amendment Rules may lead to various consequences. While the explanatory statement does not detail specific penalties, breaches of the Private Health Insurance Act 2007 can result in civil or criminal penalties, including fines and imprisonment. For instance, under section 112 of the Act, an individual who contravenes the Act may be liable for a penalty of up to $16,200 for a corporation and $3,240 for an individual. Additionally, there may be implications for the insurer's accreditation under the Act, potentially affecting their ability to offer private health insurance products. In summary, the Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 1) introduce new MBS item numbers to cover specific pathology services, ensuring that eligible patients receive appropriate rebates under their private health insurance. Health insurers and practitioners must comply with these new requirements to avoid potential penalties and ensure the continued provision of essential healthcare services.

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