Private Health Insurance (Prostheses) Amendment Rules 2009 (No. 3)

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. 3)

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 at least the minimum benefit, the prostheses must be provided in circumstances in which a medicare benefit is payable or be set out in the Private Health Insurance (Prostheses) Rules. If the complying health insurance policy also covers hospital-substitute treatment, the same requirements apply.

The Private Health Insurance (Prostheses) Rules 2009 (No. 2) as amended (the Rules) commenced on 15 August 2009.

The Schedule to the Rules has two parts:

• Part A – Prostheses; and
• Part B – Human Tissue List.

The Private Health Insurance (Prostheses) Amendment Rules 2009 (No. 3) (the Amendment Rules) update Part A of the Schedule to the Rules by:

• changing a ‘Maximum Benefit’ to one (1) item – Billing Code JJ736;
• changing the ‘Minimum Benefit’ of three (3) items, Billing Codes LM082, OE007 and OE008;
• amending typographical errors with respect to four (4) of these items, Billing Codes LM082, OE007, OE009, OE010.

The Amendment Rules commence on 26 October 2009. Details of the Amendment Rules are provided in the Attachment.

The Amendment Rules are a legislative instrument for the purposes of the Legislative Instruments Act 2003.

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.

The Sponsor of each prosthesis affected by these amendments have also been consulted and have no objections to the changes to their listed prostheses.

Authority: Section 333-20 of the Private Health Insurance Act 2007

ATTACHMENT

Details of the Private Health Insurance (Prostheses) Amendment Rules 2009 (No. 3)

1. Rule 1 provides that the title of the Rules is the Private Health Insurance (Prostheses) Amendment Rules 2009 (No. 3).

2.             Rule 2 provides that the Rules commence on 26 October 2009.

3.             Rule 3 provides that the Amendment Rules amend the Schedule to the Private Health Insurance (Prostheses) Rules 2009 (No. 2) as amended.

The amendments are as follows:

• The ‘Minimum Benefit’ of Billing Codes LM082, OE007 and OE008 are changed as outlined in the table below:  

• A ‘Maximum Benefit’ for Billing Code JJ736 is inserted, as outlined in the table below:

• The ‘Size’ description of Billing Code LM082 is amended so that ‘length’ is spelt correctly.

• The ‘Product Name’ of Billing Codes OE007, OE009 and OE010 are amended to ‘NexFix MTP Fusion System’ (from Nexfix MTP Fusion System) to correct the name of the prostheses.