EXPLANATORY STATEMENT

Private Health Insurance Act 2007

Private Health Insurance (Prostheses) Amendment Rules 2014 (No. 3)

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. 3) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2014 (No.2) (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. 2) 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 Principal 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 Principal 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 1 billing code - ZI489 - from Part A of the Schedule at the request of the sponsor;
• adding 9 new billing codes – CJ011, NG068, NG069, JJ962, AA016, OU047, OU048, ER198 and ER199 – to Part A of the Schedule following the granting of applications
• adding 2 new billing codes – ZI896 and ZI897 - to Part A of the Schedule to replace the listing of ZI489;
• increasing the minimum benefits for 2 billing codes – AS203 and AS204 – in Part A of the Schedule following a review of these prostheses;
• changing the groupings of 3 billing codes – BX320, BX312 and OU003 – in Part A of the Schedule to reflect their correct groupings;
• amending the listing details of 2 billing codes – MC668 and OU029 – in Part A of the Schedule, at the request of the sponsor;
• deleting an incorrect suffix – “>55m” in Part A of the Schedule and listing 1 billing code - NV092 – under the correct suffix “>55mm”;
• adding 1 billing code – LEN04 to Part B of the Schedule following the granting of an application;
• changing the facility name for two billing codes – TBV52 and TBV53 – in Part B to the Schedule at the request of the facility; and
• deleting 5 billing codes – APH01, HBB01, LPH01, MMH01 and SVN01 – in Part B of the Schedule as these human tissue items are no longer supplied by the facilities.

The Amendment Rules commence 6 December 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. 3)

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. 3) (the Rules) amend the Private Health Insurance (Prostheses) Rules 2014 (No. 2) (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 Principal 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 Principal 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 Amendment Rules amend the Principal Rules by:

• deleting 1 billing code - ZI489 - from Part A of the Schedule at the request of the sponsor;
• adding 7 new billing codes – CJ011, NG068, NG069, JJ962, AA016, OU047, OU048, ER198 and ER199 – to Part A of the Schedule following the granting of applications
• adding 2 new billing codes – ZI896 and ZI897 - to Part A of the Schedule to replace the listing of ZI489;
• increasing the minimum benefits for 2 billing codes – AS203 and AS204 – in Part A of the Schedule following a review of these prostheses;
• changing the groupings of 3 billing codes – BX320, BX312 and OU003 – in Part A of the Schedule to reflect their correct groupings;
• amending the listing details of 2 billing codes – MC668 and OU029 – Part A of the Schedule, at the request of the sponsor;
• deleting an incorrect suffix – “>55m” in Part A of the Schedule and listing 1 billing code - NV092 – under the correct suffix “>55mm”;
• adding 1 new billing code, LEN04, to Part B of the Schedule following the granting of an application;
• changing the facility name for two billing codes – TBV52 and TBV53 – in Part B to the Schedule at the request of the facility; and
• deleting 5 billing codes – APH01, HBB01, LPH01, MMH01 and SVN01 – in Part B of the Schedule as these human tissue items are no longer supplied by the facilities.

Human rights implications

The Amendment 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 Amendment Rules change current listing details for 29 products at the request of the sponsors or suppliers of these prostheses.  

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

The amendments made by the Amendment Rules do not reduce the minimum benefit payable for any listed prosthesis and the changes to billing codes AS203 and AS204, and the replacement of billing code ZI489 with billing codes ZI896 and ZI897 increase the minimum private health insurance benefit payable in respect of the prostheses.

Conclusion

The Amendment 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