Private Health Insurance (Benefit Requirements) Amendment Rules 2018 (No. 5)

EXPLANATORY STATEMENT

Issued by the Authority of the Minister for Health

Private Health Insurance Act 2007

Private Health Insurance (Benefit Requirements) Amendment Rules 2018 (No. 5)

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 2018 (No. 5) (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 Schedule 1 to the Amendment Rules is to amend Schedule 1 and Schedule 3 of the Principal Rules to insert 93 new Medicare Benefits Schedule (MBS) item numbers and remove 112 MBS item numbers.

The Amendment Rules implement changes to reflect updates to the MBS made by the following instruments:

• Health Insurance Legislation Amendment (2018 Measures No. 3) Regulations 2018;
• Health Insurance (Section 3C General Medical Services – MIGS Stent Implantation) Determination 2018;
• Health Insurance (Section 3C Diagnostic Imaging Services – 3D Breast Tomosynthesis) Determination 2018; and
• Health Insurance (Section 3C General Medical Services – Optical Coherence Tomography) Determination 2018.

Background

The Principal Rules 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 nursing-home type patients 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. Generally, 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 of the Amendment Rules are set out in the Attachment.

Consultation

The Amendment Rules implement changes to reflect updates made to the MBS by the instruments outlined in the Purpose section.  Those instruments implement decisions agreed by Government following recommendations of the Medical Services Advisory Committee (MSAC) and the MBS Review Taskforce (the Taskforce).

As part of the MSAC process, consultation was undertaken on the MBS item changes with professional bodies, consumer groups, the public and clinical experts for all applications considered by MSAC.

The Taskforce’s recommendations were made on the basis of work by the Diagnostic Imaging Clinical Committee, Endocrinology Clinical Committee, Spinal Surgery committee, Dermatology, Allergy and Immunology Clinical Committee and Thoracic Medicine Clinical Committee. The recommendations were released for public consultation prior to the finalisation of its recommendations to Government.

Medical advice was sought from within the Department regarding the consequential changes required in the Amendment Rules to determine the appropriate level of accommodation benefits to reflect the MBS item changes.

The Department advised the private health insurance sector about these MBS item changes through the Department’s regular communications prior to the implementation date of 1 November 2018.

The Amendment Rules commence on 1 November 2018.

The Amendment Rules is a legislative instrument for the purposes of the Legislation Act 2003.

ATTACHMENT

DETAILS OF THE PRIVATE HEALTH INSURANCE (BENEFIT REQUIREMENTS) AMENDMENT RULES 2018 (No. 5)

Section 1 Name

Section 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2018 (No.5) (the Amendment Rules).

Section 2 Commencement

Section 2 provides that the Amendment Rules commence on 1 November 2018.

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 Schedules

Section 4 provides that each instrument that is specified in a Schedule to the instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to the instrument has effect according to its terms.

Schedule 1 – Amendments

Private Health Insurance (Benefit Requirements) Rules 2011

Item 1 - Schedule 1, subsection 4(3)

Item 1 of Schedule 1 provides that the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) Schedule 1, subsection 4(3) is amended by repealing and substituting a new subsection 4(3). New subsection 4(3):

• inserts 53 new MBS items numbers (42705, 45060, 45061, 45062, 45523, 51011, 51012, 51013, 51014, 51015, 51021, 51022, 51023, 51024, 51025, 51026, 51031, 51032, 51033, 51034, 51035, 51036, 51041, 51042, 51043, 51044, 51045, 51051, 51052, 51053, 51054, 51055, 51056, 51057, 51058, 51059, 51061, 51062, 51063, 51064, 51065, 51066, 51071, 51072, 51073, 51102, 51103, 51130, 51131, 51160, 51165, 51170, 51171); and
• removes 57 items (30309, 30321, 36500, 40300, 40301, 40303, 40306, 40309, 40312, 40315, 40316, 40318, 40321, 40330, 40331, 40332, 40334, 40335, 40339, 40342, 40345, 40348, 40351, 45559, 45638, 45639, 47687, 47690, 47693, 47699, 47702, 48606, 48612, 48613, 48618, 48621, 48624, 48627, 48630, 48632, 48639, 48640, 48645, 48648, 48651, 48654, 48657, 48660, 48669, 48672, 48681, 48684, 48687, 48690, 48691, 48692, 48694).

Item 2 - Schedule 1, subsection 6(3)

Item 2 of Schedule 1 provides that Schedule 1, subsection 6(3) of the Principal Rules is amended by repealing and substituting a new subsection 6(3). New subsection 6(3):

• inserts 13 new MBS item numbers (31003, 31004, 31005, 42505, 51020, 51110, 51111, 51114, 51115, 51140, 51141, 51145, 51150); and
• removes 32 items (30197, 30308, 30313, 40324, 40327, 40333, 40336, 42705, 42783, 42786, 42789, 42792, 45020, 45552, 45555, 45557, 45586, 47684, 47696, 47705, 47711, 47717, 47720, 47723, 48615, 48636, 48642, 48663, 48666, 48675, 48678, 48693).

Item 3 - Schedule 3, subsection 5(1)

Item 3 of Schedule 1 provides that Schedule 3, subsection 5(1) of the Principal Rules is amended by repealing and substituting subsection 5(1). New subsection 5(1):

• inserts 3 new MBS item numbers (51112, 51113, 51120); and
• removes 3 items (45020,48600, 48603).

Item 4 - Schedule 3, section 8 (paragraphs under the heading “Category 2 – Diagnostic procedures & investigations”)

Item 4 of Schedule 1 provides that Schedule 3, section 8, paragraphs under the heading “Category 2 – Diagnostic procedures & investigations” of the Principal Rules is amended by repealing and substituting new paragraphs. The new paragraphs:

• insert 7 new MBS item numbers (11505, 11507, 11508, 12001, 12002, 12004, 12005); and
• remove 3 items (11222, 11225, 11509) .

Item 5 - Schedule 3, section 8 (paragraphs under the heading “Category 3 – Therapeutic procedures”)

Item 4 of Schedule 1 provides that Schedule 3, section 8, paragraphs under the heading “Category 3 – Therapeutic procedures” of the Principal Rules is amended by repealing and substituting new paragraphs. The new paragraphs:

• insert 7 new MBS item numbers (13105, 13260, 30191,36671, 36672, 36673, 42588) and
• remove 15 items (14053, 14109, 14112, 30185, 30186, 30195, 30203, 30205, 30213, 30214, 32501, 42783, 42786, 42789, 42792).

Item 6 - Schedule 3, section 8 (paragraphs under the heading “Category 4 – Oral and maxillofacial”)

Item 4 of Schedule 1 provides that Schedule 3, section 8, paragraphs under the heading “Category 4 – Oral and maxillofacial” of the Principal Rules is amended by repealing and substituting new paragraphs. The new paragraphs remove MBS item number 53600.

Item 7 - Schedule 3, section 8 (paragraphs under the heading “Category 5 – Diagnostic Imaging Services”)

Item 4 of Schedule 1 provides that Schedule 3, section 8, paragraphs under the heading “Category 5 – Diagnostic Imaging Services” of the Principal Rules is amended by repealing and substituting new paragraphs. The new paragraphs:

• insert 10 new MBS item numbers (56620, 56626, 56660, 56666, 57522, 57523, 57537, 57540, 59302, 59305); and
• remove MBS item 60100.

Statement of Compatibility with Human Rights

Prepared in accordance with Part 3 of the Human Rights (Parliamentary Scrutiny) Act 2011

Private Health Insurance (Benefit Requirements) Amendment Rules 2018 (No. 5)

This Legislative Instrument is compatible with the human rights and freedoms recognised or declared in the international instruments listed in section 3 of the Human Rights (Parliamentary Scrutiny) Act 2011.

Overview of the Legislative Instrument

The Private Health Insurance (Benefit Requirements) Amendment Rules 2018 (No. 5) amends Schedule 1 and Schedule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) to update the listing of 93 new Medicare Benefits Schedule (MBS) item numbers and the removal of 112 redundant MBS item numbers. The amendments implemented by this Legislative Instrument are consequential amendments to the Principal Rules to ensure health insurers provide an appropriate level of accommodation benefits for medical services affected by the MBS item changes agreed by Government following recommendations of the Medical Services Advisory Committee (MSAC) and the MBS Review Taskforce (Taskforce).

Human rights implications

This Legislative Instrument engages Article 12 of the International Covenant on Economic, Social and Cultural Rights, the right to health, by assisting with the progressive realisation by all appropriate means of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

Private health insurance regulation assists with the advancement of these human rights by improving the governing framework for private health insurance in the interests of consumers.  Private health insurance regulation aims to encourage insurers and providers of private health goods and services to provide better value for money to consumers; to improve information provided to consumers of private health services to allow consumers to make more informed choices when purchasing services; and requires insurers not to differentiate the premiums they charge according to individual health characteristics such as poor health.

The amendments implemented by this Legislative Instrument support access to health care reflecting current medical practice by ensuring health insurers provide an appropriate level of accommodation benefits for medical services affected by the MBS item changes.

Conclusion

This Legislative Instrument is compatible with human rights because it advances the protection of human rights.

Susan Azmi

Acting Assistant Secretary

Private Health Insurance Branch

Medical Benefits Division

Health Benefits Group

Department of Health