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.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, or the prosthesis is provided in other circumstances 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) Amendment Rules 2010 (No.2) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2010 (No. 2) as amended (the Rules) which commenced on 14 August 2010.
The Schedule to the Rules lists the prostheses for which a private health insurance benefit must be paid in the relevant circumstances. The Amendment Rules amend the Schedule to the Rules to add a new Part C. The Schedule now has three parts:
- Part A – Prostheses;
- Part B – Human Tissue List; and
- Part C – Other Prostheses Subject to Listing Criteria.
The Amendment Rules also amend the Rules to establish the listing criteria for the new Part C to the Schedule of the Private Health Insurance (Prostheses) Rules 2010 (No. 2).
Prosthetic devices will be inserted into Part C following the completion of the current Prostheses List cycle, which runs from August 2010 to February 2011.
These changes follow from amendments to the Act made by the Private Health Insurance Legislation Amendment Act (No.1) 2010.
CONSULTATION
The Amendment Rules have been made having regard to recommendations made by the PDC, a ministerially appointed committee comprised of nominees from health insurers, private hospitals, clinicians, prostheses sponsors and consumer representatives.
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.2)
1. Name of Rules
Rule 1 provides that the title of the Rules is the Private Health Insurance (Prostheses) Amendment Rules 2010 (No.2).
2. Commencement
Rule 2 provides for the Rules to commence the day after registration.
3. Amendments to the Private Health Insurance (Prostheses) Rules 2010 (No. 2)
Rule 3 provides that the Schedule to the Rules amends the Private Health Insurance (Prostheses) Rules 2010 (No.2).
Schedule Amendments to the Private Health Insurance (Prostheses) Rules 2010 (No. 2)
Items 1-3: amend rule 4 of the Rules by inserting new definitions for the following terms: ‘consultant physician’, ‘insulin infusion pump’, ‘implantable cardiac event recorder’, ‘professional attendance’, ‘certified overnight Type C Procedure’, ‘certified Type C procedure’, ‘listing application’ and ‘listing criteria’.
Item 4: makes a technical amendment to paragraph 5(b)(ii), adding the word ‘or’ at the end of the paragraph as a consequence of the addition of new paragraph 5(b)(iii) (see item 5).
Item 5: adds a paragraph (5)(b)(iii) which sets out the circumstances in which benefits are payable under a complying health insurance policy that covers hospital treatment, where a prosthesis that is an insulin infusion pump is provided. These circumstances are that the insulin infusion pump is provided for the purpose of administering insulin, the pump is provided during a professional service that is a professional attendance by a consultant physician and for which medicare benefit is payable, and the professional service is provided as a certified Type C procedure or certified overnight Type C procedure.
Item 6: makes a technical amendment to subrule 5(c), adding the word ’and’ at the end of the subrule as a consequence of the addition of new subrule 5(d) (see item 7).
Item 7: adds a subrule 5(d) which provides that rule 10 of the Rules sets out the listing criteria for the purposes of subsection 72-10(6) of the Act in relation to the granting of a listing application to list a kind of prosthesis on Part C of the Schedule. Subsection 72-10(6) of the Act provides that the Rules may set out criteria to be satisfied in order for an application to list a type of prosthesis in the Rules to be granted. Subsection 72-10(7) of the Act provides that the Minister must not grant an application to list a kind of prosthesis in the Rules if any applicable criteria have not been met.
Item 8: adds a rule 10 which sets out the criteria that must be met for an application to list a kind of prosthesis on Part C of the Schedule to be granted. These criteria are that the kind of prosthesis is either an insulin infusion pump or an implantable cardiac device.
The note to rule 10 makes clear that even where an application meets the listing criteria,
the Minister may refuse to grant the application.
Item 9: amends the Schedule to the Private Health Insurance (Prostheses) Rules 2010 (No. 2), which contains the August 2010 Prostheses List, by inserting a new Part, “Part C – Other Prostheses Subject to Listing Criteria”.