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. 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 2017 (No. 7) (the Amendment Rules) amends schedules 3, 4 and 5 of the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.
Purpose
Schedule A of the Amendment Rules
The purpose of Schedule A to the Amendment Rules is to amend Schedule 3 of the Principal Rules to add one new Medicare Benefit Schedule (MBS) number (73343). The new pathology item has been listed in co-ordination with the listing of idelalisib on the Pharmaceutical Benefits Scheme (PBS) on 1 September 2017. This MBS item was recommended by the Medical Services Advisory Committee in April 2017.
Schedule B of the Amendment Rules
Schedule B of the Amendment Rules amends Schedule 4 of the Principal Rules. The purpose of the amendment to Schedule 4 of the Principal Rules is to change the minimum benefits payable by private health insurers per night for nursing-home type patients (NHTP) at public hospitals in some states and at private hospitals nationally.
Schedule C of the Amendment Rules
Schedule C of the Amendment Rules amends Schedule 5 of the Principal Rules. The purpose of the amendment to Schedule 5 of the Principal Rules 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 benefits 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 items 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 (Pension and Rental Assistance Rates). The latest indexation of these rates took effect on 20 March 2017.
Schedule 5 of the Principal Rules requires a private 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 private 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 A of the Amendment Rules
The new pathology item (73343) was recommended by the Medical Services Advisory Committee in April 2017.
Schedule B of the Amendment Rules - Items 1 and 2
On 22 August 2017, States and Territories were asked whether they would be increasing the NHTP contribution and accommodation rates in their jurisdiction in line with increases in the Pension and Rental Assistance Rates. Queensland, Tasmania and Victoria have advised that they will increase the NHTP accommodation rates in their public hospitals from
20 September 2017. Western Australia, the Australian Capital Territory, South Australia, the Northern Territory, and New South Wales have advised that they are not increasing their NHTP accommodation rates at this time.
No specific consultation was undertaken in relation to Schedule B, item 2 of the Amendment Rules regarding private hospitals because the change was machinery in nature and linked to the twice annual Pension and Rental Assistance Rates increase. The change does not substantially alter existing arrangements.
Schedule C of the Amendment Rules
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 20 September 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. 7)
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.7) (the Amendment Rules).
Section 2 Commencement
Section 2 provides that the Amendment Rules are to commence on 20 September 2017.
Section 3 Amendment of Private Health Insurance (Benefit Requirements) Rules 2011
Section 3 provides that Schedules A, B and C to the Amendment Rules amend the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) which commenced on 1 November 2011.
Schedule A – 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 one new MBS item number (73343).
Schedule B – Amendments
Item 1 – Schedule 4, Nursing-home type patient accommodation: hospitals in all States/Territories, Clause 6 Minimum benefit, Table 1:
Item 1 of Schedule B to the Amendment Rules increases the minimum benefit payable per night for nursing-home type patients in public hospitals in the following States in clause 6, Table 1:
- Queensland $121.00 to $125.00
- Tasmania $141.10 to $142.05
- Victoria $130.00 to $134.00
Item 2 – Schedule 4, Nursing-home type patient accommodation: hospitals in all States/Territories, Clause 6 Minimum benefit, Table 2:
Item 2 of Schedule B to the Amendment Rules decreases the minimum benefit payable per night for nursing-home type patients in private hospitals in clause 6, Table 2:
- Private hospitals from $52.30 to $51.90.
Schedule C – Amendments
Item 1 – Schedule 5 - Second-tier default benefits, Clause 4. Facilities, subclause (1)
Item 1 of Schedule C to the Amendment Rules updates 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/.