Private Health Insurance (Prostheses) Amendment Rules 2009 (No.1)

EXPLANATORY STATEMENT

Issued by the Authority of the Minister for Health and Ageing

Private Health Insurance Act 2007

Private Health Insurance (Prostheses) Amendment Rules 2009 (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 2009 (No.1) (the Rules) commenced on 23 February 2009.

The Private Health Insurance (Prostheses) Amendment Rules 2009 (No.1) (the Amendment Rules) commence on 3 March 2009 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 seventeen (17) items, Billing Codes DY512, DY513, DY514, DY515, DY516, DY517, GM146, GO187, GO188, JJ749, JJ750, JJ751, JJ752, MA496, MA497, MC764, and MC766;
• changing the ‘Maximum Benefit’ of eight (8) items, Billing Codes AB001, AB002, AB010, AB012, AB013, AB018, AB020 and AB064;
• changing the ‘Minimum Benefit’ and ‘Maximum Benefit’ of two (2) items, Billing Codes GM137 and GM138;
• changing the ‘Minimum Benefit’ and sub-group of one (1) item, Billing Code GM145;
• changing the sub-group and description of three (3) items, Billing Codes EK086, EK087 and EK088;
• changing the group, sub-group and suffix of two (2) items, Billing Codes MC813 and MC814;
• changing the sub-group of two (2) items, Billing Codes EK089 and GM140;
• changing the product name of three (3) items, Billing Codes MA499, MA500 and MA501;
• adding three (3) new items, Billing Codes MG031, ZI706 and ZI707;
• deleting two (2) items, Billing Codes DE276 and MM001;
• deleting three (3) headings: (i)‘Generation 4’, after Billing Code BS139; (ii)‘Prostheses, Joint’ after Billing Code SY052; and (iii) ‘Group 14c: Lacrimal duct drainage prostheses: Punctal occlusion’ after Billing Code DE177.
   

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 2009 (No.1)

1.  Name of Rules

Rule 1 provides that the title of the Rules is the Private Health Insurance (Prostheses) Amendment Rules 2009 (No.1).

2.  Commencement

Rule 2 provides for the Rules to commence on 3 March 2009.

3.  Amendment of the Schedule to the Private Health Insurance (Prostheses) Rules 2009 (No.1)

Rule 3 provides for the amendments to the Schedule to the Private Health Insurance (Prostheses) Rules 2009 (No.1).

The amendments include:

•      the addition of Billing Codes MG031, ZI706 and ZI707 as listed in the table below;

•      the deletion of Billing Codes DE276 and MM001;
•      changes to: (i) the ‘Minimum Benefits’ for seventeen items (Billing Codes DY512, DY513, DY514, DY515, DY516, DY517, GM146, GO187, GO188, JJ749, JJ750, JJ751, JJ752, MA496, MA497, MC764 and MC766); (ii) the ‘Maximum Benefits’ for eight items (Billing Codes AB001, AB002, AB010, AB012, AB013, AB018, AB020 and AB064); and (iii) both the ‘Minimum Benefit’ and ‘Maximum Benefits’ for two items (Billing Codes GM137 and GM138), as listed in the table below.

•       changes to product name, description, size, sub-group, suffix and/ or minimum benefit for eleven items (Billing Codes EK086, EK087, EK088, EK089, GM140, GM145, MA499, MA500, MA501, MC813 and MC814) as listed in the table below:

•       the deletion of three headings: (i)‘Generation 4’, after Billing Code BS139; (ii)‘Prostheses, Joint’ after Billing Code SY052; and (iii) ‘Group 14c: Lacrimal duct drainage prostheses: Punctal occlusion’ after Billing Code DE177.