Private Health Insurance (Prostheses) Amendment Rules 2010 (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 2010 (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 at least the minimum benefit, the prosthesis has to be provided in circumstances in which a medicare benefit is payable, and, if the Private Health Insurance (Prostheses) Rules set out conditions that must be satisfied in relation to the provision of the prosthesis in those circumstances, those conditions are satisfied. 

If the complying health insurance policy also covers hospital-substitute treatment, the same requirements apply.

The Private Health Insurance (Prostheses) Rules 2010 (No. 2) (the Rules) commenced on 14 August 2010.

The Schedule to the Rules has two parts:

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

The Private Health Insurance (Prostheses) Amendment Rules 2010 (No.1) (the Amendment Rules) commence on 5 October 2010 and amend the Schedule to the Rules.

The Amendment Rules update Part A of the Schedule to the Rules by:

• deleting twelve (12) Billing Codes GL007, SK125, SK120, SK121, SK122, SK123, SK124, SR047, SR048, SR049, SK186 and SK046;
• changing the billing codes for PU057, PU058 and ST988 to PU059, PU060 and SK510 respectively. The Billing Codes PU057, PU058 and ST988 were incorrectly given to three new products in the Rules.  These billing codes had been used before for other products that were subsequently deleted;
• changing the ‘size’ of one (1) item, Billing Code CZ020;
• transferring four (4) Billing Codes from Orthotech Pty Ltd to Biomet Australia Pty Ltd. These changes were effected by deleting Billing Codes OH240, OH241, OH123 and OH347 and replacing them with Billing Codes BH103, BH104, BH105 and BH106;
• duplicating five (5) items under an additional sponsor by adding the following Billing Codes BH100, BH101, BH102, BH107 and BH108;
• reinstating three (3) items that were incorrectly removed when the Rules were made, Billing Codes SY060, SY071 and SY270; and
• removing any redundant headings as a result of deletion of various Billing Codes.

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

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 2010 (No. 1)

1.  Name of Rules

Rule 1 provides that the title of the Rules is the Private Health Insurance (Prostheses) Amendment Rules 2010 (No. 1).

2.  Commencement

Rule 2 provides for the Rules to commence on 5 October 2010.

3.  Amendment of the Schedule to the Private Health Insurance (Prostheses) Rules 2010 (No. 2)

Rule 3 provides for the amendments to the Schedule to the Private Health Insurance (Prostheses) Rules 2010 (No. 2).

The amendments include:

• changing the ‘size’ of Billing Code CZ020, as outlined in the table below; 

• deleting twelve (12) Billing Codes GL007, SK046, SK120, SK121, SK122, SK123, SK124, SK125, SK186, SR047, SR048 and SR049.

• transferring four (4) Billing Codes from Orthotech Pty Ltd to Biomet Australia Pty Ltd. These changes were effected by deleting Billing Codes OH240, OH241, OH123 and OH347 and replacing them with Billing Codes BH103, BH104, BH105 and BH106.  These amendments are outlined in the table below:

• changing three (3) Billing Codes from PU057, PU058 and ST988 to PU059, PU060 and SK510 as outlined in the table below:

• reinstating three (3) items that were incorrectly removed when the Rules were made, Billing Codes SY060, SY071 and SY270, as outlined in the table below:

• duplicating five (5) Billing Codes under an additional sponsor with the addition of BH100, BH101, BH102, BH107 and BH108, as outlined in the table below: 

• removing any redundant headings as a result of deletion of various Billing Codes.