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

Administered by Department of Health, Disability and Ageing

Legislation au F2014L01573 Rules Not in force Legislative Instrument

Legislation content

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

 

Overview

The Private Health Insurance (Prostheses) Amendment Rules 2014 (No. 3), enacted under the authority of the Private Health Insurance Act 2007, address the need to update the Prostheses List with new prostheses and correct any errors in the current listings. These Amendment Rules were introduced to ensure that the Prostheses List remains current and reflective of advancements in technology and surgical procedures, while also rectifying any minor drafting errors. This legislative instrument was made by the Minister for Health in accordance with the authority granted by section 333-20 of the Act. The policy objective of these amendments is to maintain and enhance the quality and relevance of the prostheses covered under private health insurance policies, thereby supporting the right to health by ensuring access to necessary medical devices. These Amendment Rules implement changes to the Prostheses List by adding new prostheses, updating existing entries, and removing outdated or incorrect entries. Such amendments ensure that the benefits provided by private health insurance policies align with current medical practices and technologies, thus supporting the ongoing health and wellbeing of insured individuals. The amendments do not diminish the benefits available for any prosthesis and, in some cases, increase the minimum benefits payable. The compatibility of these rules with human rights is affirmed, as they support the right to health by facilitating access to necessary and advanced medical prostheses.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules 2014 (No. 3) amends the Private Health Insurance (Prostheses) Rules 2014 (No. 2) to reflect decisions made on applications to change details of products on the Prostheses List since the Principal Rules were made and to correct a minor drafting error. These rules apply to private health insurers, healthcare providers, and consumers in Australia, particularly those with policies that cover hospital treatment and hospital-substitute treatment. The rules affect the types of prostheses that must be covered by complying health insurance policies, as specified in the Schedule to the Principal Rules. The Amendment Rules introduce changes such as adding new prostheses to the list, updating the minimum benefits for certain prostheses, and correcting errors in the billing codes and facility names. These amendments ensure that the list remains current with technological advancements and industry changes. The rules are a legislative instrument under the Legislative Instruments Act 2003 and are compatible with human rights, specifically advancing the right to health by ensuring that the highest attainable standard of physical and mental health is maintained. The Amendment Rules have a nationwide application across Australia, impacting all entities involved in the private health insurance sector. The rules do not specify any exclusions or exemptions but operate within the broader framework of the Private Health Insurance Act 2007. The application of the rules can be further extended or restricted through subordinate instruments, as permitted by section 333-20 of the Act. The changes made by the Amendment Rules aim to keep the Prostheses List up-to-date, reflecting the current standards and practices in the provision of prosthetic devices.

Key Provisions

The Private Health Insurance (Prostheses) Amendment Rules 2014 (No. 3) amend the Private Health Insurance (Prostheses) Rules 2014 (No. 2) to adjust the details of products on the Prostheses List. These changes include the deletion of one billing code, the addition of nine new billing codes, the replacement of two billing codes, an increase in minimum benefits for two billing codes, changes to the groupings of three billing codes, amendments to the listing details of two billing codes, the correction of an incorrect suffix, the addition of one billing code, changes to facility names for two billing codes, and the deletion of five billing codes. These changes were made following decisions on applications, reviews, and requests from sponsors and suppliers. These rules impose obligations on private health insurers to comply with the updated Prostheses List. Insurers must ensure that their policies meet the requirements for listed prostheses, which include providing benefits for the provision of a prosthesis under specified circumstances. This means that for hospital treatment, there must be a benefit for the provision of a listed prosthesis when a Medicare benefit is payable or in other circumstances specified in the rules. If the policy also covers hospital-substitute treatment, the same requirements apply. The rules also mandate that insurers review and adjust their policies to reflect these amendments. Failure to comply with these rules may result in civil or administrative penalties. While specific penalties are not detailed in the explanatory statement, non-compliance with regulations under the Private Health Insurance Act 2007 can lead to significant consequences for insurers, including fines and other regulatory actions. The updated Prostheses List aims to ensure that patients have access to the most current and effective medical prostheses, thereby enhancing the quality of health care provided under private health insurance policies.

Legal classification tags

Area of Law
Health Law
Instrument
Regulation
Concepts
Definitions & Interpretation
Regulatory Standards
Enforcement Powers

Interactions

Authorises

All Versions

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.