Private Health Insurance (Prostheses) Amendment Rules 2009 (No. 2)

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. 2)

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. 2) (the Rules) commence on 15 August 2009.

The Private Health Insurance (Prostheses) Amendment Rules 2009 (No. 2) (the Amendment Rules) commence on 15 August 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 two (2) items, Billing Codes IS001 and DV230;
• deleting the ‘Maximum Benefit’ of eleven (11) items, Billing Codes SY517, SY518, MO295, MO296, MO297, MO298, MO299, MO300, MO301, MO303, and MO304;
• changing the ‘Minimum Benefit’ and deleting the ‘Maximum Benefit’ of two (2) items, Billing Codes DV029 and DV010;
• transferring thirteen (13) Billing Codes from Orthotech Pty Ltd to Lima Orthopaedics Australia Pty Ltd. These changes were effected by deleting the following Billing Codes (OH082, OH083, OH084, OH085, OH086, OH087, OH088, OH089, OH090, OH114, OH115, OH138, OH327) and replacing them with the following Billing Codes (LC036, LC037, LC038, LC039, LC040, LC041, LC042, LC043, LC044, LC045, LC046, LC047, LC048);
• adding two (2) items, Billing Codes SP032 and MF034; and
• inserting the heading “Reconstruction Sheeting, Plastic Surgery” and subheading “Medical Vision Australia Pty Ltd” after the Billing Code MP011.

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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. 2)

1.  Name of Rules

Rule 1 provides that the title of the Rules is the Private Health Insurance (Prostheses) Amendment Rules 2009 (No. 2).

2.  Commencement

Rule 2 provides for the Rules to commence on 15 August 2009.

3.  Amendment of the Schedule to the Private Health Insurance (Prostheses) Rules 2009 (No. 2)

Rule 3 provides for the amendments to the Schedule to the Private Health Insurance (Prostheses) Rules 2009 (No. 2).

The amendments include:

•      transferring thirteen (13) Billing Codes from Orthotech Pty Ltd to Lima Orthopaedics Australia Pty Ltd. These changes were effected by deleting the following Billing Codes (OH082, OH083, OH084, OH085, OH086, OH087, OH088, OH089, OH090, OH114, OH115, OH138, OH327) and replacing them with the following Billing Codes (LC036, LC037, LC038, LC039, LC040, LC041, LC042, LC043, LC044, LC045, LC046, LC047, LC048).  These amendments are outlined in the table below:

• adding two (2) items, Billing Codes SP032 and MF034, as outlined in the table below:

•      changing the ‘Minimum Benefit’ of Billing Codes IS001 and DV230, as outlined in the table below;  

• deleting the ‘Maximum Benefit’ of Billing Codes SY517, SY518, MO295, MO296, MO297, MO298, MO299, MO300, MO301, MO303, and MO304, as outlined in the table below: 

• changing the ‘Minimum Benefit’ and deleting the ‘Maximum Benefit’ of Billing Codes DV010 and DV029, as outlined in the table below:

• inserting  the heading “Reconstruction Sheeting, Plastic Surgery” and subheading “Medical Vision Australia Pty Ltd” after the Billing Code MP011.