Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 4)

Administered by Department of Health, Disability and Ageing

Legislation au F2013L01839 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. 4)

 

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.

The Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 4) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2013 (No.1) (the Principal Rules) to correct drafting errors in the Principal Rules.

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 Principal Rules. 

The Amendment Rules will vary the Principal Rules as follows:

  • correct errors in the product details for billing code WC312;
  • remove redundant subheading from the Schedule;
  • correct the amount of minimum benefit payable by insurers for billing codes BS082, MH014, MH015, BS171, OL009, WC213, OL010, ST884, BR005, BR006, SHV01, SHV 02 and SHV03;
  • delete billing codes BI286, BI287 and BI264, at the request of the product sponsor;
  • reinsert billing codes BH286, BH287 and BH264 following their inadvertent deletion from the Principal Rules;
  • move billing code HW517 to its correct product group; and
  • add billing codes OH467, SYN01, SYN02, SYN03, SYN04, SYN05, SYN06 and SYN07 that were incorrectly omitted from the Principal Rules.

 


Consultation

In accordance with section 17 of the Legislative Instruments Act 2003, the Department consulted with the sponsor of each prosthesis affected by these amendments. There are no objections to the amendments. The Department has received a standing Regulatory Impact Statement exemption from the Department of Finance and Deregulation.

The Amendment Rules commence 8 November.  

The Amendment 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. 4)

 

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

The Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 4) (the Rules) amend the Private Health Insurance (Prostheses) Rules 2013 (No. 1) (the Principal Rules) to correct drafting errors in the Principal Rules.

 

Item 4 of the table in subsection 72-1(2) of Part 3-3 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 (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, identified by billing code, are currently set out in the Schedule to the Principal Rules. 

 

The Rules amend the Principal Rules by:

  • correcting errors in the product details for billing code WC312;
  • removing redundant subheading from the Schedule;
  • correcting the amount of minimum benefit payable by insurers for billing codes BS082, MH014, MH015, BS171, OL009, WC213, OL010, ST884, BR005, BR006, SHV01, SHV02 and SHV03;
  • deleting billing codes BI286, BI287 and BI264;
  • reinserting billing codes BH286, BH287 and BH264 following their inadvertent deletion from the Principal Rules;
  • moving billing code HW517 to its correct product group; and
  • adding billing codes OH467, SYN01, SYN02, SYN03, SYN04, SYN05, SYN06 and SYN07 that were incorrectly omitted from the Principal Rules.

 


Human rights implications

The Rules engage the following human rights:

 

Right to Health

 

The right to health – the right to the enjoyment of the highest attainable standard of physical and mental health – is contained in article 12(1) of the International Covenant on Economic Social and Cultural Rights (ICESCR).  Whilst the UN Committee on Economic Social and Cultural Rights (the Committee) has stated that the right to health is not to be understood as a right to be healthy, it does entail a right to a system of health protection which provides equality of opportunity for people to enjoy the highest attainable level of health.

 

The addition of eight new items to the Schedule of the Principal Rules and re-insertion of eight items inadvertently omitted from the Schedule of the Principal Rules as no gap prostheses or gap permitted prostheses will ensure that an insured person with appropriate cover will receive a minimum benefit for the provision of the prosthesis as hospital treatment or, where applicable hospital-substitute treatment, and:

  • the prosthesis is provided in circumstances where a Medicare benefit is payable and any relevant conditions in the Rules are met; or
  • the prosthesis is provided in other circumstances specified in the Rules and any relevant conditions are met.

 

The addition of new items will increase the amount of choice an insured person can have in relation to the type of prostheses for which they must receive a minimum benefit.  This will impact positively on the right to health of insured persons.

 

The Rules also remove entries for three prostheses at the request of the sponsors of these prostheses. The sponsors of these prostheses are no longer supplying these prostheses for use to privately insured persons in Australia.

 

Generally the prostheses removed from the Rules have been replaced by newer models due to upgraded technologies or advancements in surgical procedures. 

 

The benefit decrease to seven prostheses does not reduce Australians enjoyment of the right to health. The benefit is the amount payable by private health insurers for the use of a product in surgery. The benefit decrease will reduce costs to hospitals and insurers, and out‑of-pocket expenses for patients.

 

A recent review of all prostheses established a single benefit levels for each group of like products. The group of prostheses products related to the benefit decrease can be separated into two clusters of products related to those that are either less or more expensive, based on the pre-review benefits. The significant benefit increase of the seven affected prostheses above their pre-review benefits passed substantial cost increases to hospitals, insurers and patients. The benefit decrease for the seven prostheses returns the benefits to pre-review levels for these items and reduces the unintended higher costs to hospitals, insurers and patients.

 

There is a relative equitable utilisation between the less and more expensive prostheses. Clinician preference and surgical requirements are the general drivers for the use of particular products. The benefit decrease will have no effect on Australians rights to health

 

Conclusion

The Rules are compatible with human rights because they advance the protection of human rights, specifically the right to health and, to the extent that right is limited the limitation is reasonable, necessary and proportionate.

Lyndall Moore

a/g First Assistant Secretary

Medical Benefits Division

Department of Health

 

Overview

The Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 4) were enacted to amend the Private Health Insurance (Prostheses) Rules 2013 (No. 1) and correct drafting errors therein. The Private Health Insurance Act 2007, enacted by the Parliament of Australia, addresses the gap in ensuring that private health insurance policies provide adequate coverage for prostheses, particularly in hospital treatment scenarios. The policy objective of these amendments is to rectify errors, remove redundancy, and update benefits to ensure compliance with the requirements set out in the Act. The Department of Health consulted with relevant stakeholders, including product sponsors, and no objections were received to the proposed amendments. These amendments ensure that insured persons receive the appropriate benefits for prostheses and maintain equitable access to healthcare services.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 4) amends the Private Health Insurance (Prostheses) Rules 2013 (No.1) to correct various drafting errors, ensuring compliance with the Private Health Insurance Act 2007. These rules apply to private health insurers and insured persons in Australia, focusing on the specification of prostheses covered under health insurance policies and the minimum benefits insurers must provide for these prostheses. The rules are designed to enhance the clarity and accuracy of the requirements for prostheses covered by health insurance policies, thereby ensuring that insured persons receive the correct benefits for specified prostheses. The changes include correcting errors in product details, adjusting benefit amounts, and adding or reinserting omitted prostheses. These amendments aim to improve the accuracy of the billing codes and ensure that the benefits provided align with the intended coverage under the Act. The rules are applicable nationally, as they pertain to private health insurance practices across Australia. The Department of Health has consulted with relevant stakeholders, including the sponsors of the affected prostheses, and there are no objections to the amendments. The rules are compatible with human rights, particularly the right to health, by ensuring that insured persons receive appropriate benefits for prostheses, thereby protecting their health and well-being. The amendments do not impose any new limitations on human rights but rather aim to correct previous errors, thereby maintaining a balance between the rights of insured persons and the financial sustainability of the health insurance system.

Key Provisions

The Private Health Insurance (Prostheses) Amendment Rules 2013 (No. 4) amend the Private Health Insurance (Prostheses) Rules 2013 (No. 1) to correct various drafting errors. The amendments primarily involve updates to the product details and billing codes for prostheses covered under private health insurance policies. Specifically, the Amendment Rules correct errors in product details for billing code WC312, remove a redundant subheading, adjust the minimum benefits payable by insurers for several billing codes, delete and reinsert certain billing codes, correct the product grouping for billing code HW517, and add previously omitted billing codes to the Schedule (sections 2 and 3). The obligations imposed by the Amendment Rules on the parties they govern include ensuring that the corrected and updated information is accurately reflected in all relevant documents and systems. Private health insurers must update their policies and billing systems to reflect the changes made by the Amendment Rules. This includes updating the minimum benefits payable for certain prostheses and ensuring that the correct prostheses are included in the list of covered items. Additionally, the Department of Health must ensure that the Schedule to the Principal Rules accurately reflects the changes made by the Amendment Rules. There are no explicit offences, penalties, or civil/criminal consequences for breach of the Amendment Rules themselves. However, private health insurers who fail to comply with the updated information and requirements set out in the Amendment Rules may face regulatory action or penalties under the Private Health Insurance Act 2007. Such penalties could include fines or other enforcement actions taken by the Australian Prudential Regulation Authority (APRA) or other relevant regulatory bodies. The maximum penalties for breaches of the Private Health Insurance Act 2007 can vary depending on the specific provisions breached and the severity of the breach, but they can include significant financial penalties and other enforcement measures.

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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.