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 |
Overview
The Private Health Insurance (Prostheses) Amendment Rules 2008 (No. 1) were enacted to amend the schedule of the Private Health Insurance (Prostheses) Rules 2008, which were made under the Private Health Insurance Act 2007. These amendments were introduced to address the need for regular updates to the benefits associated with various prostheses covered under private health insurance policies. The rules were developed following recommendations from the Prostheses and Devices Committee, which includes representatives from various stakeholders such as private health insurers, hospitals, clinicians, and consumer groups. The overarching policy objective is to ensure that the benefits provided for prostheses are aligned with current clinical practices and technological advancements.
The Private Health Insurance (Prostheses) Amendment Rules 2008 (No. 1) update the minimum and maximum benefits for certain prostheses, add new items, and commence on 8 July 2008. These amendments are intended to reflect changes in medical technology and treatment protocols, thereby ensuring that policyholders receive appropriate coverage for their healthcare needs. The rules were made under the authority granted by Section 333-20 of the Private Health Insurance Act 2007, facilitating the necessary adjustments to comply with evolving healthcare standards.
Scope and Application
The Private Health Insurance (Prostheses) Amendment Rules 2008 (No.1) amend the Private Health Insurance (Prostheses) Rules 2008 (No.1) to update the minimum benefits for various prostheses listed in the Schedule to the Rules. The amendment applies to private health insurers operating in Australia, as they are required to comply with the rules when offering health insurance policies that cover hospital treatment and prostheses. The amendment was made in response to recommendations from the Prostheses and Devices Committee, which included representatives from private health insurers, hospitals, clinicians, prostheses and devices suppliers, and consumer representatives. The amendment includes changes to the minimum benefits of thirteen prostheses, as well as changes to both the minimum and maximum benefits for three prostheses. Two new prostheses have also been added to the list. These changes aim to ensure that the benefits provided by private health insurance policies are fair and appropriate, and that patients have access to necessary prostheses. The amendment applies nationally across Australia and is in force from 8 July 2008.
Key Provisions
The Private Health Insurance (Prostheses) Amendment Rules 2008 (No.1) outline changes to the benefits and coverage associated with certain prostheses under the Private Health Insurance Act 2007. These amendments, which came into effect on 8 July 2008, primarily involve updating the minimum benefits for various prostheses listed in the Schedule to the Private Health Insurance (Prostheses) Rules 2008 (No.1). Specifically, Section 333-20 of the Act empowers the Minister to make rules regarding prostheses, including specifying minimum benefits for prostheses that complying health insurance policies must cover (Section 72-1(2)). This section also mandates that for a private health insurer to be required to pay the minimum benefit, a Medicare benefit must be payable for the professional service associated with the provision of the listed prosthesis.
These rules impose obligations on private health insurers to adhere to the specified minimum and maximum benefits for certain prostheses when offering policies that cover hospital treatment or hospital-substitute treatment. Insurers must ensure that their policies comply with these updated benefits, which are listed in the amended Schedule to the Rules. This includes adding new prostheses to the list, such as the Pressure Pulse Generator Meniett 20 and PTP Implants, and adjusting the benefits for existing prostheses. Failure to comply with these rules can lead to significant legal and financial repercussions for insurers, as they may be liable for any shortfalls in coverage that result from non-compliance.
The consequences of non-compliance with these provisions can be severe. Breaches of the rules could result in civil penalties, including fines and other sanctions as outlined in the Act. While the explanatory statement does not explicitly detail the maximum penalties, under the Private Health Insurance Act 2007, penalties for non-compliance can be substantial, reflecting the importance of ensuring adequate coverage for policyholders. Additionally, insurers may face legal action from policyholders who suffer financial losses due to inadequate coverage, further underscoring the need for strict adherence to these rules.