Private Health Insurance (Benefit Requirements) Amendment Rules 2019 (No. 1)

Administered by Department of Health, Disability and Ageing

Legislation au F2019L00048 Rules Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Issued by the Authority of the Minister for Health

 

Private Health Insurance Act 2007

 

Private Health Insurance (Benefit Requirements) Amendment Rules 2019 (No. 1)

 

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.

 

Purpose

The purpose of the Private Health Insurance (Benefit Requirements) Amendment Rules 2019 (No. 1) (the Amendment Rules) is to amend the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) as a consequence of the addition of new item 73351 to the Medicare Benefits Schedule (MBS) by the Health Insurance (Section 3C Co-Dependent Pathology Services) Amendment Determination 2019 with effect from 1 February 2019.

 

Consequently, the Amendment Rules amends the Principal Rules by adding MBS item number 73351 to clause 8 of Schedule 3 of the Principal Rules.

 

Details of the Amendment Rules are set out in the Attachment.

 

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 (NHTP) (Schedule 4) and second tier default benefits (Schedule 5).

 

Schedule 1 of the Principal Rules 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.

 

Consultation

Medical advice was sought from medical officers within the Department to determine the appropriate level of accommodation benefits in respect of the MBS item added to the Principal Rules by the Amendment Rules.

 

The Amendment Rules implement changes to reflect the update made to the MBS by the instrument outlined in the Purpose section.

 

The above instrument listed in the Purpose section implements a decision agreed by the Australian Government following recommendations of the Medical Services Advisory Committee (MSAC). The change in the determination was 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 Amendment Rules commence on 1 February 2019.

 

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 2019 (No. 1)

 

Section 1 Name of Rules

 

Section 1 provides that the title of the Rules is the Private Health Insurance (Benefit Requirements) Amendment Rules 2019 (No. 1) (the Amendment Rules).

 

Section 2 Commencement

 

Section 2 provides that the Amendment Rules commence on 1 February 2019.

 

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 Amendment of Private Health Insurance (Benefit Requirements) Rules 2011

 

Section 4 provides that the Schedule of the Amendment Rules amend the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules).

 

Schedule 1 – Amendments

 

Items 1 - Schedule 3, clause 8 (paragraphs under the heading “Category 6 – Pathology services”)

 

Item 1 amends the Principal Rules by adding MBS item number 73351 to clause 8 of Schedule 3 of the Principal Rules.

 

MBS item 73351 was added to the MBS by Health Insurance (Section 3C Co-Dependent Pathology Services) Amendment Determination 2019, which commence on 1 February 2019.

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules 2019 (No. 1) were enacted to amend the Private Health Insurance (Benefit Requirements) Rules 2011, necessitated by the inclusion of new item 73351 in the Medicare Benefits Schedule (MBS) via the Health Insurance (Section 3C Co-Dependent Pathology Services) Amendment Determination 2019. These Amendment Rules were made under the authority of section 333-20 of the Private Health Insurance Act 2007 and commenced on 1 February 2019. The primary objective of these rules is to ensure that the minimum benefit requirements for private health insurance reflect the updates in the MBS, thereby maintaining consistency and fairness in the provision of healthcare services. The rules were developed after consultation with medical officers within the Department and are in line with the recommendations of the Medical Services Advisory Committee (MSAC), which involved extensive consultation with professional bodies, consumer groups, the public, and clinical experts.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules 2019 (No. 1) apply to health insurers regulated under the Private Health Insurance Act 2007, with the primary objective of updating the minimum benefit requirements in line with changes to the Medicare Benefits Schedule (MBS). These Amendment Rules are a direct response to the inclusion of new MBS item number 73351, introduced by the Health Insurance (Section 3C Co-Dependent Pathology Services) Amendment Determination 2019, which became effective from 1 February 2019. This amendment ensures that the benefit requirements for certain pathology services are aligned with the latest MBS updates, thereby impacting the scope of benefits that health insurers must provide for privately insured patients. The Amendment Rules specifically modify the Private Health Insurance (Benefit Requirements) Rules 2011 by incorporating the new MBS item into the relevant schedule, ensuring that the updated benefit requirements are legally enforceable from the specified commencement date.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules 2019 (No. 1) amend the Private Health Insurance (Benefit Requirements) Rules 2011 by adding a new item to the Medicare Benefits Schedule (MBS). Specifically, MBS item number 73351, which was added to the MBS by the Health Insurance (Section 3C Co-Dependent Pathology Services) Amendment Determination 2019, is now included in clause 8 of Schedule 3 of the Principal Rules. This addition pertains to same day hospital accommodation benefits for privately insured patients. The Amendment Rules were made under Section 333-20 of the Private Health Insurance Act 2007 and came into effect on 1 February 2019. These Amendment Rules impose obligations on health insurers to ensure that the benefits they provide align with the new MBS item number 73351. Health insurers must now include this item in their calculations for the benefits payable to patients for pathology services. This change is intended to ensure that patients who require co-dependent pathology services are appropriately compensated under their private health insurance policies. The Private Health Insurance (Benefit Requirements) Amendment Rules 2019 (No. 1) do not explicitly state any offences, penalties, or consequences for non-compliance. However, health insurers are still subject to the general provisions of the Private Health Insurance Act 2007. Any failure to comply with the Act or the benefit requirements set out in the Principal Rules and the Amendment Rules could potentially lead to enforcement actions by the Australian Prudential Regulation Authority (APRA). In severe cases, this might include fines, corrective measures, or other regulatory actions. The specific penalties would be determined based on the nature and severity of the breach, as well as any relevant provisions in the Act.

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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.