EXPLANATORY STATEMENT
Issued by the Authority of the Minister for Health and Ageing
Private Health Insurance Act 2007
Private Health Insurance (Prostheses) Amendment Rules 2008 (No.1)
Section 333-20 of the Private Health Insurance Act 2007 (the Act) provides that the Minister may make Private Health Insurance (Prostheses) Rules, providing for matters required or permitted by Part 3-3 of the Act, or necessary or convenient in order to carry out or give effect to Part 3-3 of the Act.
Item 4 of the table in subsection 72-1(2) of Part 3-3 of the Act provides for requirements that a complying health insurance policy that covers hospital treatment must meet. There must be a minimum benefit for the provision of a prosthesis of a kind listed in the Private Health Insurance (Prostheses) Rules.
Item 4 of the table provides that in order for a private health insurer to be required to pay the minimum benefit, a Medicare benefit must be payable in respect of the professional service associated with the provision of the listed prosthesis.
If the complying health insurance policy also covers hospital-substitute treatment, the same requirements apply.
The Private Health Insurance (Prostheses) Rules 2008 (No.1) (the Rules) commence on 8 July 2008.
The Private Health Insurance (Prostheses) Amendment Rules 2008 (No.1) (the Amendment Rules) commence on 8 July 2008 and amend the Schedule to the Rules.
The Schedule to the Rules has two parts:
- Part A – Prostheses; and
- Part B – Human Tissue List.
The Amendment Rules update Part A of the Schedule to the Rules by:
- changing the minimum benefit of thirteen (13) items, billing codes MU043, MU051, GO169, SN377, AD253, AD168, AD185, AD186, AD170, AD146, AD172, DE282 and OE001;
- changing the maximum and minimum benefit of three (3) items, billing codes JJ004, BI860 and BI184; and
- adding two (2) items, billing codes MC256 and ET041.
CONSULTATION
The Amendment Rules have been made having regard to recommendations made by the Prostheses and Devices Committee (PDC), a ministerially appointed Committee comprised of nominees from private health insurers, hospitals, clinicians, prostheses and devices suppliers, and consumer representatives.
In making their recommendations, the PDC were advised by Clinical Advisory Groups, other clinical experts, and benefits negotiators, all appointed by the PDC.
Details of the Amendment Rules are set out in the Attachment.
The Amendment Rules are a legislative instrument for the purposes of the Legislative Instruments Act 2003.
Authority: Section 333-20 of the
Private Health Insurance
Act 2007
ATTACHMENT
DETAILS OF THE PRIVATE HEALTH INSURANCE (PROSTHESES) AMENDMENT RULES 2008 (No.1)
1. Name of Rules
Rule 1 provides that the title of the Rules is the Private Health Insurance (Prostheses) Amendment Rules 2008 (No.1).
2. Commencement
Rule 2 provides for the Rules to commence on 8 July 2008.
3. Amendment of the Schedule to the Private Health Insurance (Prostheses) Rules 2008 (No.1)
Rule 3 provides for the amendments to the Schedule to the Private Health Insurance (Prostheses) Rules 2008 (No.1).
The amendments include:
- The addition of billing codes MC256 and ET041 as listed in the table below;
Billing code | Product Name | Description | Size | Minimum Benefit | Maximum Benefit | Notations |
MC256 | Pressure Pulse Generator Meniett 20 | Composition – Polycarbonate | One size only | $5,060.00 |
| To be claimed only where medical therapy such as lifestyles (general health assessment and stress reduction) and oral medications (diuretics, antiemetics, anti-vertigo and steroids) have been unsuccessful. |
ET041 | PTP Implants | PTP Implants are solid, irregularly textured medical grade Polydimethyisiloxane Elastomer implants suspended in a hydrogel carrier | One size only | $9,200.00 |
|
|
- Changes to the minimum benefits for thirteen items (billing codes MU043, MU051, GO169, SN377, AD253, AD168, AD185, AD186, AD170, AD146, AD172, DE282 and OE012) and changes to both the minimum and maximum benefits for three items (billing codes JJ004, BI860 and BI184) as listed in the table below.
Billing Code | Minimum benefit | Maximum benefit |
MU043 | $3,300.00 |
|
MU051 | $4,200.00 |
|
GO169 | $6,750.00 |
|
SN377 | $670.00 |
|
AD253 | $7,540.00 |
|
AD168 | $3,500.00 |
|
AD185 | $6,550.00 |
|
AD186 | $6,550.00 |
|
AD170 | $1,250.00 |
|
AD146 | $895.00 |
|
AD172 | $615.00 |
|
DE282 | $14,500.00 |
|
OE012 | $5,261.00 |
|
JJ004 | $21.00 |
|
BI860 | $2,000.00 | $2,708.00 |
BI184 | $1,040.00 | $1,964.00 |