Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 8)

Administered by Department of Health, Disability and Ageing

Legislation au F2017L01401 Rules Not in force Legislative Instrument

Legislation content

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).


 

 

 

 

 

 

 

 

 

 

 

 

 

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 8) were enacted to amend the Private Health Insurance (Benefit Requirements) Rules 2011, which established the minimum benefit requirements for various types of hospital treatment under the Private Health Insurance Act 2007. The purpose of the Amendment Rules was to adjust the Medicare Benefits Schedule (MBS) item numbers by inserting 24 new items and removing 33 existing ones, thereby updating the minimum benefits payable for hospital treatments. These amendments were made under the authority granted by section 333-20 of the Act and were implemented following consultations with the Medical Services Advisory Committee and the MBS Review Taskforce. The changes were designed to reflect current clinical practices and recommendations, ensuring that private health insurance policies continue to meet necessary benefit requirements as outlined by the Act. The Amendment Rules were enacted by the Parliament of Australia and were made in response to the need to update the MBS item numbers in the Principal Rules to align with recent medical advancements and recommendations. The policy objective behind these amendments was to ensure that private health insurance policies provide adequate coverage for necessary medical services, thereby protecting consumers and maintaining the integrity of the private health insurance system. The Department of Health engaged in consultations with various stakeholders, including professional bodies, consumer groups, and clinical experts, to gather input on the proposed changes before finalising the recommendations to the Government.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 8) amends the Private Health Insurance (Benefit Requirements) Rules 2011 by inserting 24 new Medicare Benefits Schedule (MBS) item numbers and removing 33 MBS item numbers. These amendment rules apply to health insurers providing private health insurance in Australia. The changes aim to update the minimum benefit requirements for hospital treatment, including psychiatric, rehabilitation, and palliative care, and other hospital treatments, as well as same day hospital accommodation benefits for privately insured patients across all states and territories. The amendment rules are designed to reflect the latest decisions and recommendations from the Medical Services Advisory Committee and the MBS Review Taskforce, which underwent public consultation. The changes to the MBS item numbers affect the classification and payment levels for different types of hospital treatments and procedures, ensuring that the private health insurance system remains current and reflective of medical advancements and clinical practices. The amendment rules commenced on 1 November 2017 and are a legislative instrument under the Legislation Act 2003.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules 2017 (No. 8) (Amendment Rules) revise the Private Health Insurance (Benefit Requirements) Rules 2011 (Principal Rules) by introducing changes to the Medicare Benefits Schedule (MBS) item numbers. These amendments are primarily concentrated in Schedules 1 and 3 of the Principal Rules, which detail the minimum benefit requirements for hospital treatment. Section 1 of the Amendment Rules confirms the title of these rules, while Section 2 specifies that they come into effect on 1 November 2017. Section 3 clarifies that these rules are made under the authority of the Private Health Insurance Act 2007. The Amendment Rules impose obligations on private health insurers to align their benefit offerings with the updated MBS item numbers as per the revised schedules. For example, insurers must now include the newly added MBS item numbers in their coverage for certain types of hospital treatments, such as advanced surgical, obstetric, and surgical patient categories. Similarly, they must cease coverage for the MBS item numbers that have been removed from the schedules. These changes ensure that the benefits provided by insurers meet the updated regulatory standards and reflect the most current clinical practices and technological advancements. Failure to comply with these amendments could result in non-compliance with the Private Health Insurance Act 2007. While the Amendment Rules themselves do not explicitly state penalties for non-compliance, breaches of the Act generally could lead to enforcement actions by the Australian Prudential Regulation Authority (APRA). Such actions might include financial penalties, corrective measures, or even legal proceedings against the non-compliant insurer. Additionally, consumers may be adversely affected if their health insurance policies do not cover the newly mandated MBS items or if they are still charged for the removed items. The Amendment Rules also necessitate that insurers update their policies and communicate these changes to their policyholders. Insurers must ensure that their benefits accurately reflect the updated MBS item numbers, and they must inform their clients about any changes to their coverage. This transparency is crucial to maintaining consumer trust and ensuring that policyholders are aware of the services covered by their health insurance plans. Failure to adequately communicate these changes could result in consumer dissatisfaction and potential regulatory scrutiny.

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Sourced from the Federal Register of Legislation at 26 August 2026. For the latest information on Australian Government law please go to https://www.legislation.gov.au.