Private Health Insurance (Prostheses) Amendment Rules 2014 (No.2)

Administered by Department of Health, Disability and Ageing

Legislation au F2014L00733 Not in force Legislative Instrument

Legislation content

EXPLANATORY STATEMENT

 

Private Health Insurance Act 2007

 

Private Health Insurance (Prostheses) Amendment Rules 2014 (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.

The Private Health Insurance (Prostheses) Amendment Rules 2014 (No. 2) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2014 (No.1) (the Principal Rules) to reflect decisions made on applications to change details of products on the Prostheses List since the Principal Rules were made and to correct one minor drafting error.

The Principal Rules were previously amended by the Private Health Insurance (Prostheses) Amendment Rules 2014 (No. 1) to correct drafting errors.

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:

  • deleting 3 billing codes - TO121, TO122 and BH171 - from Part A of the Schedule at the request of the sponsor;
  • adding a suffix to 1 product DE366 and changing the benefit to $161.00, in Part A of the Schedule;
  • adding 2 new billing codes - BH360 and BH361 - to Part A of the Schedule to replace the listing of BH171;
  • changing the name of a product group in Part B of the Schedule (“Bone - Milled 20-29gr) to amend an error;
  • increase the minimum benefits of 61 human tissue products supplied by the NSW Bone Bank - NBB62, NBB61, NBB60, NBB65, NBB64, NBB63, NBB05, NBB09, NBB59, NBB17, NBB57, NBB13, NBB56, NBB55, NBB10, NBB11, NBB12, NBB15, NBB14, NBB18, NBB54, NBB21, NBB24, NBB22, NBB23, NBB26, NBB50, NBB51, NBB25, NBB29, NBB30, NBB27, NBB28, NBB53, NBB31, NBB06, NBB49, NBB47, NBB01, NBB02, NBB69, NBB33, NBB68, NBB72, NBB73, NBB70, NBB67, NBB71, NBB35, NBB36, NBB46, NBB45, NBB37, NBB44, NBB41, NBB43, NBB42, NBB66, NBB07, NBB40 and NBB38.

 

The Amendment Rules commence 27 June 2014.  

 

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 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 2014 (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

The Private Health Insurance (Prostheses) Amendment Rules 2014 (No. 2) (the Rules) amend the Private Health Insurance (Prostheses) Rules 2014 (No. 1) (the Principal Rules) to reflect decisions made on applications to change details of products on the Prostheses List since the Principal Rules were made and to amend a minor drafting error.

 

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:

  • deleting 3 billing codes - TO121, TO122 and BH171 - from Part A of the Schedule at the request of the sponsor;
  • adding a suffix to 1 product DE366 and increasing the benefit to $161.00, in Part A of the Schedule;
  • adding 2 new billing codes - BH360 and BH361 - to Part A of the Schedule to replace the listing of BH171;
  • changing the name of a product group in Part B of the Schedule (“Bone - Milled 20-29gr) to amend an error;
  • increase the minimum benefits of 61 human tissue products supplied by the NSW Bone Bank - NBB62, NBB61, NBB60, NBB65, NBB64, NBB63, NBB05, NBB09, NBB59, NBB17, NBB57, NBB13, NBB56, NBB55, NBB10, NBB11, NBB12, NBB15, NBB14, NBB18, NBB54, NBB21, NBB24, NBB22, NBB23, NBB26, NBB50, NBB51, NBB25, NBB29, NBB30, NBB27, NBB28, NBB53, NBB31, NBB06, NBB49, NBB47, NBB01, NBB02, NBB69, NBB33, NBB68, NBB72, NBB73, NBB70, NBB67, NBB71, NBB35, NBB36, NBB46, NBB45, NBB37, NBB44, NBB41, NBB43, NBB42, NBB66, NBB07, NBB40 and NBB38.

 

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 Rules change current listing details for 66 products at the request of the sponsors or suppliers of these prostheses.  

 

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

 

The amendments made by the Rules do not reduce the minimum benefit payable for any listed prosthesis and the changes to all affected NSW Blood Bank prostheses and billing code DE366, and the replacement of billing code BH171 with billing codes BH360 and BH361, increase the minimum private health insurance benefit payable in respect of the prosthesis.

 

Conclusion

The Rules are compatible with human rights because they advance the protection of human rights, specifically the right to health.

 

Shane Porter

Assistant Secretary

Medical Benefits Division

Department of Health

 

Overview

The Private Health Insurance (Prostheses) Amendment Rules 2014 (No. 2) were enacted to amend the Private Health Insurance (Prostheses) Rules 2014 (No.1) and address updates and corrections in the listing of prostheses. This legislative instrument was introduced by the Minister under section 333-20 of the Private Health Insurance Act 2007, allowing for the making of rules necessary or convenient to carry out or give effect to the provisions of Part 3-3 of the Act. The policy objective behind these amendments was to ensure that the Prostheses List remains current and accurate, reflecting technological advancements and correcting errors in the initial listing. The rules were developed following consultations with the sponsors of the affected prostheses and are compatible with human rights as they aim to provide equality of opportunity for people to enjoy the highest attainable level of health. These Amendment Rules were enacted to refine the details of prostheses listed under the Prostheses List, including deletions, additions, and corrections to billing codes and product benefits. The objective was to maintain an up-to-date and accurate list of prostheses covered under private health insurance policies, thereby ensuring that patients have access to the latest medical technologies and improvements in surgical procedures. The rules also increased the minimum benefits for certain prostheses, further supporting the right to health by providing enhanced coverage for necessary medical devices. The changes introduced by the Amendment Rules reflect the ongoing commitment to improving healthcare outcomes and aligning the Prostheses List with current medical standards.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules 2014 (No. 2) apply to the Private Health Insurance (Prostheses) Rules 2014 (No. 1), regulating the listing and benefits of prostheses covered by private health insurance policies in Australia. These rules are applicable to entities and individuals involved in the private health insurance industry, particularly those providing or administering health insurance policies. The scope of these rules is national, impacting the entire Commonwealth of Australia as they pertain to the regulation of private health insurance. They do not specify any exclusions or exemptions and operate under the jurisdictional reach of the Commonwealth. The Amendment Rules amend the Principal Rules by adjusting the Prostheses List, reflecting decisions on applications to change prostheses details since the Principal Rules were made, and correcting a minor drafting error. The changes include removing three billing codes, modifying the benefit of one product, adding two new billing codes, correcting a product group name, and increasing the minimum benefits for 61 human tissue products supplied by the NSW Bone Bank. The amendment rules are effective as of 27 June 2014.

Key Provisions

The Private Health Insurance (Prostheses) Amendment Rules 2014 (No. 2) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2014 (No.1) (the Principal Rules) to update the list of prostheses covered by private health insurance policies. These changes reflect decisions made on applications to alter details of products on the Prostheses List since the Principal Rules were enacted and correct a minor drafting error. The Amendment Rules introduce specific changes to the Prostheses List, including the deletion of three billing codes (TO121, TO122, and BH171), the addition of a suffix to product DE366 with an adjusted benefit of $161.00, the introduction of two new billing codes (BH360 and BH361) to replace BH171, and a correction to the name of a product group in Part B of the Schedule. Additionally, the minimum benefits for 61 human tissue products supplied by the NSW Bone Bank are increased. These changes are intended to ensure that the Prostheses List remains accurate and reflective of current medical practices and technologies. The Amendment Rules impose several obligations on parties governed by the Private Health Insurance Act 2007. Insurers must ensure that their policies comply with the updated Prostheses List as set out in the Amendment Rules. This includes providing benefits for listed prostheses in specified circumstances, such as when a Medicare benefit is payable or under other conditions outlined in the rules. Insurers must also ensure that their policies adhere to the updated minimum benefits for certain prostheses. The Amendment Rules also require that any changes to the Prostheses List are communicated effectively to policyholders, ensuring that they are aware of any changes that may affect their coverage. Failure to comply with the Amendment Rules may result in civil consequences for insurers. Policies that do not meet the requirements of the updated Prostheses List may be deemed non-compliant, leading to potential disputes with policyholders. Additionally, insurers may face regulatory scrutiny and enforcement actions if they are found to be non-compliant with the rules. Although the Amendment Rules themselves do not specify criminal penalties for non-compliance, breaches of the broader Private Health Insurance Act 2007 can lead to criminal charges, including fines and imprisonment, depending on the severity and intent of the breach. The Amendment Rules also stipulate that any objections to the changes proposed must be communicated to the Department of Health. In this instance, the Department reports that there were no objections to the proposed amendments, indicating a consensus among stakeholders regarding the necessity of these updates. The Department has also obtained a standing Regulatory Impact Statement exemption from the Department of Finance and Deregulation, highlighting the minimal impact of these amendments on the broader regulatory landscape. The compatibility of the Amendment Rules with human rights is affirmed, particularly in relation to the right to health, as the changes aim to enhance the quality and effectiveness of prostheses covered by private health insurance.

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