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. 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 2017 (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 Schedules A, B and C to the Amendment Rules is to amend Schedule 1 and Schedule 3 of the Principal Rules to insert 24 new Medicare Benefits Schedule (MBS) item numbers and remove 33 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 (2017 Measures No. 2) Regulation 2017;
- Health Insurance (Section 3C Pathology Services – BRCA Gene Testing No.2) Determination 2017;
- Health Insurance (Section 3C General Medical Services – Mechanical Thrombectomy) Determination 2017;
- Health Insurance (General Medical Services Table) Amendment (Obstetrics) Regulations 2017; and
- Health Insurance (Section 3C General Medical Services – Transcatheter Aortic Valve Implantation) Determination 2017,
24 new MBS item numbers have been added and 33 MBS item numbers have been removed. Medical advice was sought from within the Department regarding this amendment.
The above Regulations and Determinations implement decisions agreed by Government following recommendations of the Medical Services Advisory Committee (MSAC) and the MBS Review Taskforce (the Taskforce). The changes in the Regulations and Determinations were released for public comment prior to finalisation of the recommendations to Government as below:
- As part of the MSAC process, consultation was undertaken with professional bodies, consumer groups, the public and clinical experts for applications put forward for consideration by the Committee.
- The Taskforce recommended changes arose from the Taskforce’s first round of clinical committees, which included gastroenterology, diagnostic imaging, ear nose and throat surgery, obstetrics, and the Principles and Rules Committee. The MBS Review is conducted by expert committees and working groups focusing on specific areas of the MBS. The recommendations were released for public consultation prior to the finalisation of its recommendations to Government.
The Department notified the private health insurance sector about these MBS item changes prior to the implementation date of 1 November 2017.
The Amendment Rules commence on 1 November 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. 8)
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.8) (the Amendment Rules).
Section 2 Commencement
Section 2 provides that the Amendment Rules are to commence on 1 November 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 A – 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 three new MBS items numbers (35414, 38276 and 38495).
Item 2 - Schedule 1, Part 2 – Type A Procedures, Clause 5 Obstetric patient, subclause (2)(a)(ii)
Item 2 amends Schedule 1, Part 2 – Type A Procedures, Clause 5 Obstetric patient, subclause (2)(a)(ii) of the Principal Rules by inserting four new MBS item numbers (16534, 16533, 16531 and 16530), and removing one item (16525).
Item 3 - Schedule 1, Part 2 – Type A Procedures, Clause 6 Surgical patient, subclause (3)
Item 3 amends Schedule 1, Part 2 – Type A Procedures, Clause 6 Surgical patient, subclause (3) of the Principal Rules by inserting four new MBS item numbers (40708, 40705, 40704, and 40701) and removing 14 items (41820, 30110, 35687, 35712, 35716, 36658, 36662, 41792, 41819, 30620, 30638, 30675, 35676, and 35683).
Schedule B – Amendments
Item 1 - Schedule 3, Part 2 – Type B Procedures, Clause 4 Band 1, subclause (1)(a) T8: Surgical Operations
Item 1 amends Schedule 3, Part 2 – Type B Procedures, Clause 4 Band 1, subclause (1)(a) T8: Surgical Operations of the Principal Rules by removing one MBS item number (30476).
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 six new MBS item numbers (111, 117, 120, 6080, 6081 and 40702) and removing 14 MBS item numbers (30041, 30102 30106, 30282, 30493, 35512, 35516, 35526, 35617, 35639, 36660, 37622, 41665, and 41800).
Schedule C – Amendments
Item 1 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 2 – Diagnostic procedures & investigations, D1
Item 1 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 2 – Diagnostic procedures & investigations, D1of the Principal Rules by inserting two new MBS item numbers (12320 and 12322) and removing three new MBS item numbers (12309, 12318, and 12323).
Item 2 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 3 – Therapeutic procedures, T4
Item 2 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 3 – Therapeutic procedures, T4 of the Principal Rules by inserting two new MBS item numbers (16407 and 16408).
Item 3 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 3 – Therapeutic procedures, T8
Item 3 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 3 – Therapeutic procedures, T8 of the Principal Rules by inserting one new MBS item number (40707).
Item 4 - Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 6 – Pathology services, P7
Item 4 amends Schedule 3, Part 3 – Type C Procedures, Clause 8 Interpretation, Category 6 – Pathology services, P7 of the Principal Rules by inserting two new MBS item numbers (73297 and 73296).