Private Health Insurance (Benefit Requirements) Amendment Rules (No. 3) 2019

Administered by Department of Health, Disability and Ageing

Legislation au F2019L00493 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 (No. 3) 2019

 

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 (No. 3) 2019 (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 115 to the Medicare Benefits Schedule (MBS) by the Health Insurance (Section 3C General Medical Services – Unscheduled specialist attendance) Determination 2019 with effect from 1 April 2019.

 

Consequently, the Amendment Rules amends the Principal Rules by adding MBS item number 115 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 generally 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 of Health 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 April 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 (No. 3) 2019

 

Section 1 Name of Rules

 

Section 1 provides that the title of the instrument is the Private Health Insurance (Benefit Requirements) Amendment Rules (No. 3) 2019 (the Amendment Rules).

 

Section 2 Commencement

 

Section 2 provides that the Amendment Rules commence on 1 April 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 Schedules

 

Section 4 provides that the instrument specified in the Schedule of the Amendment Rules will be amended or repealed as set out in the applicable items in the Schedule, and any other item in a Schedule to this instrument has effect according to its terms.

 

Schedule 1 – Amendments

 

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

 

Item 1 amends the Private Health Insurance (Benefit Requirements) Rules 2011 (the Principal Rules) by adding MBS item number 115 to clause 8 of Schedule 3 of the Principal Rules.

 

MBS item 115 was added to the MBS by the Health Insurance (Section 3C General Medical Services – Unscheduled specialist attendance) Determination 2019, which commences on 1 April 2019.

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Overview

The Private Health Insurance (Benefit Requirements) Amendment Rules (No. 3) 2019 were introduced to update the Private Health Insurance (Benefit Requirements) Rules 2011, as mandated by the Private Health Insurance Act 2007. This legislation was enacted to ensure that private health insurers provide adequate benefits to policyholders for various medical services, aligning with the Medicare Benefits Schedule (MBS). The rules were formulated by the Minister for Health under the authority granted by section 333-20 of the Act. The primary objective of these amendments is to incorporate the new MBS item 115 into the benefit requirements for private health insurance, effective from 1 April 2019, thereby ensuring that private health insurers cover the new unscheduled specialist attendance services as per the MBS. This amendment reflects the updated medical services agreed upon following recommendations by the Medical Services Advisory Committee and subsequent consultations with various stakeholders.

Scope and Application

The Private Health Insurance (Benefit Requirements) Amendment Rules (No. 3) 2019 applies to private health insurers in Australia and amends the Private Health Insurance (Benefit Requirements) Rules 2011. This legislation is enacted under the authority of the Private Health Insurance Act 2007, which governs the operation of private health insurance in Australia. The Amendment Rules are designed to reflect changes to the Medicare Benefits Schedule (MBS) and ensure that health insurers provide appropriate benefits for specified medical services. Specifically, these rules update the benefit requirements to include new MBS item number 115, which pertains to unscheduled specialist attendance. The Amendment Rules apply nationally across all states and territories and are effective from 1 April 2019. While the Amendment Rules primarily aim to update benefit requirements, they do not establish new exclusions or exemptions beyond what is already stipulated in the Principal Rules. However, the scope of application is extended through the incorporation of new MBS items, ensuring that the benefit structures remain current with medical service updates.

Key Provisions

The Private Health Insurance (Benefit Requirements) Amendment Rules (No. 3) 2019 primarily amend the Private Health Insurance (Benefit Requirements) Rules 2011 by incorporating a new Medicare Benefits Schedule (MBS) item number 115 into the existing benefit requirements (Section 1). This amendment was necessitated by the addition of MBS item 115 to the MBS by the Health Insurance (Section 3C General Medical Services – Unscheduled specialist attendance) Determination 2019, which took effect from 1 April 2019 (Section 2). The rules are made under the authority provided by section 333-20 of the Private Health Insurance Act 2007, which allows the Minister to make rules that are necessary or convenient to carry out or give effect to Part 3-3 of the Act (Section 3). The amendment specifically modifies Schedule 3 of the Principal Rules, adding MBS item number 115 to the list of items under the "Category 1 – Attendances" heading in clause 8 (Schedule 1, Item 1). The amendment imposes obligations on health insurers to ensure they comply with the updated benefit requirements, particularly concerning the new MBS item number 115. Health insurers must now provide the specified benefits associated with MBS item 115 as outlined in the amended Principal Rules (Schedule 3, clause 8). This includes ensuring that the benefits for privately insured patients who require unscheduled specialist attendance are met according to the new guidelines set forth in the MBS item 115. The amendment also includes provisions for the periodic review of benefits, ensuring that they remain aligned with the MBS and any other relevant changes. There are no specific offences or penalties mentioned in the Amendment Rules themselves. However, non-compliance with the Private Health Insurance Act 2007 and the updated benefit requirements could potentially result in civil or criminal penalties under the broader legislative framework of the Act. For example, breaches of the Act could lead to enforcement actions by the Australian Health Insurance Commission, which could include fines or other corrective measures. The exact penalties for non-compliance would depend on the specific nature of the breach and the provisions of the Private Health Insurance Act 2007.

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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.