Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 2)

Administered by Department of Health, Disability and Ageing

Legislation au F2013L00265 Rules Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Private Health Insurance Act 2007

 

Private Health Insurance (Prostheses) Amendment Rules 2013 (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 benefit for the provision of a prosthesis, of a kind listed in the Private Health Insurance (Prostheses) Rules (i.e. a listed prosthesis), in specified circumstances and under any specified conditions.  The specified circumstances are that the listed prosthesis is provided in circumstances in which a Medicare benefit is payable or those other circumstances which are set out in the Private Health Insurance (Prostheses) Rules.

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

Listed prostheses are currently set out in the Schedule to the Private Health Insurance (Prostheses) Rules 2012 (No. 2) (the Principal Rules).  The Principal Rules currently include the following 10 prostheses (the VAIOS System):

  • VAIOS Humeral Head (Billing Code OH 386)
  • VAIOS Reverse Humeral Insert (Billing Code OH390)
  • VAIOS Humeral Neck (Billing Code OH387)
  • VAIOS Humeral Stem (Billing Code OH388)
  • VAIOS Cemented Glenoid (Billing Code OH385)
  • VAIOS Glenoid Metal Back (Billing Code OH383)
  • VAIOS Humeral Metal Back Reverse (Billing Code OH389)
  • VAIOS Glenoid Insert (Billing Code OH384)
  • VAIOS Glenoid Dome (Billing Code OH391)
  • VAIOS Locking screw (Billing Code OH392)

The Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 1) (the Amending Rules) were made on 8 February 2013 and commence on 5 March 2013.  The Amending Rules will replace the current Schedule to the Principal Rules with a new Schedule of listed prostheses.  The VAIOS System is not listed in the Amending Rules.  

The purpose of the Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 2) is to maintain the listing of the VAIOS System, as required by an interim Court order. 

The 10 components of the VAIOS System will be listed with their current billing codes, product details and minimum benefits.

These Rules will commence immediately after the commencement of the Amending Rules on 5 March 2013.  

Consultation

No consultation has been taken in connection with these Rules.  They have been made in response to an interim Court order and it would therefore be inappropriate to undertake consultation about them. 

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


Statement of Compatibility with Human Rights

Prepared in accordance with Part 3 of the Human Rights (Parliamentary Scrutiny) Act 2011

Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 2)

This Legislative Instrument is compatible with the human rights and freedoms recognised or declared in the international instruments listed in section 3 of the Human Rights (Parliamentary Scrutiny) Act 2011.

Overview of the Legislative Instrument

Item 4 of the table in subsection 72-1(2) of the Private Health Insurance Act 2007 provides for requirements that a complying health insurance policy that covers hospital treatment must meet.  There must be a benefit for the provision of a prosthesis of a kind listed in the Private Health Insurance (Prostheses) Rules in specified circumstances and under any specified conditions.  The specified circumstances are that the prosthesis is provided in circumstances where a Medicare benefit is payable or any other circumstance set out in those Rules. 

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

Listed prostheses are currently set out in the Schedule to the Private Health Insurance (Prostheses) Rules 2012 (No. 2) (the Principal Rules).  The Schedule currently includes the following 10 prostheses (the VAIOS prostheses): VAIOS Humeral Head; VAIOS Reverse Humeral Insert; VAIOS Humeral Neck; VAIOS Humeral Stem; VAIOS Cemented Glenoid; VAIOS Glenoid Metal Back; VAIOS Humeral Metal Back Reverse; VAIOS Glenoid Insert; VAIOS Glenoid Dome; and VAIOS Locking screw.

A new Schedule to the Principal Rules is to be substituted by the Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 1) (the Amending Rules), made on 8 February 2013 and commencing on 5 March 2013.  The VAIOS prostheses are not included in the Amending Rules. 

The Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 2) (the Rules) will amend the Schedule to the Principal Rules from 5 March 2013 to maintain the listing of the VAIOS prostheses, as required by an interim Court order. 

Human rights implications

These Rules are being made to give effect to an interim order of the Federal Court to maintain the listing of the VAIOS prostheses pending further proceedings.  However, the maintenance of the listing of the VAIOS prostheses does not have any negative impact on human rights.  In particular, it does not limit the rights to health or social security and the requirement for the payment of insurance benefits for the VAIOS prostheses is not restricted on the basis of sex, age, race etc.

Doug Fawns

Assistant Secretary

Medical Benefits Division

Department of Health and Ageing

Overview

The Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 2) were enacted to amend the schedule of listed prostheses under the Private Health Insurance Act 2007. These rules were introduced in response to an interim Court order to ensure the continued listing of the VAIOS System prostheses, which was excluded from the new schedule proposed by the Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 1). This legislative action was taken by the Minister for Health under the authority granted by Section 333-20 of the Private Health Insurance Act 2007. The policy objective of these rules is to maintain the listing of specified prostheses to ensure that complying health insurance policies continue to provide coverage for these critical medical devices, as mandated by the Act. The rules were made without consultation due to the urgency imposed by the Court order and are compatible with human rights as declared in relevant international instruments.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 2) pertain to the Private Health Insurance Act 2007, which applies to private health insurance providers and policies within Australia. These rules specify the requirements for the inclusion of certain prostheses in health insurance policies that cover hospital treatment or hospital-substitute treatment. The rules ensure that listed prostheses, which are currently set out in the Private Health Insurance (Prostheses) Rules 2012, are provided under specified conditions, particularly where a Medicare benefit is payable or under other circumstances outlined in the rules. The amendment rules are designed to maintain the listing of specific prostheses, such as the VAIOS System, following an interim Court order. The rules are legislative instruments and are subject to the Legislative Instruments Act 2003. They have been declared compatible with human rights as per the Human Rights (Parliamentary Scrutiny) Act 2011, ensuring that the maintenance of the listing does not negatively impact human rights, including rights to health and social security.

Key Provisions

The Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 2) amend the existing Private Health Insurance (Prostheses) Rules 2012 (No. 2) to ensure that the VAIOS System of prostheses remains listed for coverage under complying health insurance policies. This is necessary to comply with an interim Court order. The VAIOS System, which includes ten specific prostheses such as the VAIOS Humeral Head and VAIOS Cemented Glenoid, was set to be removed from the list under the Amending Rules made earlier in 2013. However, the purpose of these Amendment Rules is to maintain the VAIOS prostheses in the list of covered items, ensuring that health insurance policies continue to provide benefits for these prostheses in circumstances where a Medicare benefit is payable or as otherwise specified in the Rules (Section 333-20). These Rules impose specific obligations on health insurers and policyholders. Health insurers must ensure that their policies provide benefits for the listed VAIOS prostheses under the specified conditions. This includes providing coverage when a Medicare benefit is payable or under any other circumstances outlined in the Rules. Policyholders, in turn, must be aware of the specific prostheses covered by their policies and the conditions under which these benefits apply. The Rules ensure that the VAIOS System remains available for those who require these specific prostheses for hospital or hospital-substitute treatment, aligning with the requirements set out in the Private Health Insurance Act 2007. The Act does not explicitly detail offences, penalties, or consequences for non-compliance with the Rules. However, failure to comply with the requirements of the Act, such as providing the specified benefits for listed prostheses, could result in legal action from policyholders who may claim that their rights under the insurance policy have been breached. Additionally, the Minister may take regulatory action against insurers who do not adhere to the Rules, which could include fines or other sanctions. While specific penalties are not detailed in the Rules, the overarching legal framework of the Private Health Insurance Act 2007 provides a basis for enforcement and compliance.

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Sourced from the Federal Register of Legislation at 26 August 2026. For the latest information on Australian Government law please go to https://www.legislation.gov.au.