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. 4)
Authority
Section 333-20 of the Private Health Insurance Act 2007 (the Act) provides that the Minister may make Private Health Iznsurance (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. 4) (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 of the Principal Rules to insert two new Medicare Benefits Schedule (MBS) item numbers and amend Schedule 3 of the Principal Rules to insert one new MBS item number and remove one MBS item number that has been moved to Schedule 1.
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 (NHTPs) (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
Schedule 1 of the Amendment Rules
Departmental medical advice was provided on the recommended listing of the MBS item 41618 within the Rules (Type B). Item 41618 was added to the 1 May 2017 Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 3). On 3 May 2017, Departmental medical advice was reviewed and the classification of the item was amended from Type B to a Type A Advanced Surgical.
In early May 2017, the Minister had agreed to list a new (interim) cataract surgery item 42705 to allow it to be claimed with the insertion of eye stent devices with the same fee as existing cataract surgery item 42702. The listing of this service will remain until
31 December 2017 to allow time for Medical Services Advisory Committee (MSAC) to consider funding of the service. The Department has consulted with the ophthalmology medical profession and device manufacturers about MBS ophthalmology items and any associated prostheses. This MBS item was listed on the MBS as of 1 May 2017, however this number was not included in the 1 May 2017 Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 3) due to a timing error within the Department.
Schedule 3 of the Amendment Rules
Ramsay Health made an enquiry to the Department about the addition of MBS item 30406. This item has since been recommended by a Departmental medical advisor for inclusion into the Principal Rules.
The Amendment Rules commence on the day after registration on the Federal Register of Legislation.
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. 4)
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.4) (the Amendment Rules).
Section 2 Commencement
Section 2 provides that the Amendment Rules commence on the day after registration on the Federal Register of Legislation.
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.
Item 1 amends Schedule 1, Part 2 Type A procedures, Clause 4 Advanced surgical patient of the Principal Rules by reclassifying an existing MBS item number (41618). MBS item 41618 is an existing item (currently listed as a Type B procedure) for insertion of partially implantable active middle ear implants for patients with mild to severe sensorineural hearing loss.
Item 2 - Schedule 1, Part 2 Type A procedures, Clause 6 Surgical patient.
Item 2 amends Schedule 1, Part 2 Type A procedures, Clause 6 Surgical patient of the Principal Rules by inserting a current MBS item number (42705). MBS item 42705 lists a new cataract surgery item to allow it to be claimed with the insertion of eye stent devices with the same fee as existing cataract surgery item 42702. This will allow the service to be available on the MBS on an interim basis for patients with glaucoma who are not adequately responsive to topical anti-glaucoma medications or who are intolerant of anti-glaucoma medication. The listing of this service will remain until 31 December 2017 to allow time for Medical Services Advisory Committee (MSAC) to consider funding of the service. This MBS item was listed on the MBS as of 1 May 2017, however this number was not included in the 1 May 2017 Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 3) due to a timing error within the Department.
Item 3 - Schedule 3, Part 2 Type B procedures, Clause 5 Non-band specific Type B day procedures.
Item 3 amends Schedule 3, Part 2 Type B procedures, Clause 5 Non-band specific Type B day procedures of the Principal Rules by removing one MBS item number (41618). MBS item 41618 has been moved to Schedule 1, Part 2 – Type A procedures, Clause 4 Advanced surgical patient.
Item 4 - Schedule 3, Part 3 Type C procedures, Clause 8 Interpretation, Category 3 – Therapeutic procedures, T8.
Item 4 amends Schedule 3, Part 3 Type C procedures, Clause 8 Interpretation, Category 3 – Therapeutic procedures, T8 of the Principal Rules by inserting a current MBS item number (30406). MBS item 30406 is a procedure where a needle is inserted in the abdomen to drain excess fluid (ascites). The item has been in operation since 1 November 1992, however never included in the Principle Rules because it is highly unlikely this procedure would be the primary reason for hospitalisation.