Private Health Insurance (Prostheses) Amendment Rules 2015 (No. 2)

Administered by Department of Health, Disability and Ageing

Legislation au F2015L01111 Rules Not in force Legislative Instrument

Legislation content

EXPLANATORY STATEMENT

 

Private Health Insurance Act 2007

 

Private Health Insurance (Prostheses) Amendment Rules 2015 (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 2015 (No. 2) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2015 (No.1) (the Principal Rules) to reflect a decision made since the Principal Rules were made on an application to list a new product.

Item 4 of the table in subsection 72-1(2) of Part 3-3 of the Act provides for benefit 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:

  • adding 1 new billing code – AS209 – to Part A of the Schedule following the granting of an application for listing;

The Amendment Rules commence 10 July 2015.

Consultation

In accordance with section 17 of the Legislative Instruments Act 2003, the Department consulted with the sponsor of each kind of 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 2015 (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 2015 (No. 2) (the Rules) amend the Private Health Insurance (Prostheses) Rules 2015 (No. 1) (the Principal Rules) to reflect a decision made since the Principal Rules were made on an application to list a new product.

 

Item 4 of the table in subsection 72-1(2) of Part 3-3 of the Private Health Insurance Act 2007 provides for benefit 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:

  • adding 1 new billing code – AS209 – to Part A of the Schedule following the granting of an application for listing;

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 add 1 new billing code to the Schedule to the Principal Rules. This change has a beneficial impact on the right to health in Australia, ensuring that a minimum benefit is required to be paid for the provision of this prosthesis under private health insurance policies covering hospital treatment, where relevant conditions are met.   

 

The amendment made by the Amendment Rules does not reduce the minimum benefit payable for any listed prosthesis.

 

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

Private Health Insurance Branch

Medical Benefits Division

Department of Health

 

Overview

The Private Health Insurance (Prostheses) Amendment Rules 2015 (No. 2) was enacted to amend the Private Health Insurance (Prostheses) Rules 2015 (No. 1), addressing a decision made since the initial rules were established regarding an application to list a new product. The Act, Private Health Insurance Act 2007, was introduced by the Parliament of Australia to ensure that complying health insurance policies provide benefits for the provision of prostheses under specific conditions, particularly when a Medicare benefit is payable or under other circumstances outlined in the Act. These rules, made by the Minister under the authority granted by section 333-20 of the Act, aim to maintain the integrity of the health insurance framework by updating the list of prostheses covered by private health insurance policies. The Amendment Rules were designed to enhance the right to health by ensuring that a minimum benefit is required for the provision of newly listed prostheses, thus aligning with the policy objective of protecting and advancing human rights, particularly the right to health as recognised in international instruments.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules 2015 (No. 2) amends the Private Health Insurance (Prostheses) Rules 2015 (No. 1) to reflect a decision made on an application to list a new product. These rules are applicable to entities providing private health insurance policies that cover hospital treatment in Australia, specifically concerning the benefit requirements for prostheses. The amendment is focused on adding a new billing code, AS209, to the Schedule of the Principal Rules following the granting of a listing application. This change ensures that a minimum benefit is required for the provision of the specified prosthesis under private health insurance policies that cover hospital treatment, where relevant conditions are met. The rules apply nationwide, reflecting the national scope of private health insurance regulation in Australia. There are no stated exclusions or exemptions in these Amendment Rules. The rules commenced on 10 July 2015, and their scope is limited to the specific amendments concerning the listing of prostheses in private health insurance policies. The Amendment Rules do not extend or restrict the application of the overarching Private Health Insurance Act 2007 but rather provide detailed specifications necessary to implement the Act's provisions regarding prostheses.

Key Provisions

The Private Health Insurance (Prostheses) Amendment Rules 2015 (No. 2) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2015 (No.1) (the Principal Rules) to reflect a decision made on an application to list a new product. The main change introduced by these rules is the addition of a new billing code, AS209, to Part A of the Schedule of the Principal Rules, which lists prostheses eligible for benefits under a complying health insurance policy. This new addition follows the granting of an application for listing, indicating that the prosthesis in question has met the criteria set by the Department for inclusion in the schedule (Section 72-1(2) of Part 3-3 of the Private Health Insurance Act 2007). The Amendment Rules came into effect on 10 July 2015. The Amendment Rules impose specific obligations on parties governed by the Private Health Insurance Act 2007. For private health insurers, the primary obligation is to ensure that any complying health insurance policy covering hospital treatment includes a benefit for the provision of prostheses listed in the amended Schedule. This benefit must be provided under the specified circumstances, which include cases where a Medicare benefit is payable or under other conditions outlined in the Principal Rules. If the policy also covers hospital-substitute treatment, the same benefit requirements apply. Insurers must also ensure that the addition of the new billing code AS209 is reflected in their policies and communications with policyholders. Failure to comply with the requirements set out in the Amendment Rules may result in civil or criminal penalties under the Private Health Insurance Act 2007. While the Amendment Rules themselves do not specify penalties, non-compliance with the Act generally can lead to significant financial penalties. Under section 334 of the Act, a person who contravenes a requirement to provide benefits for listed prostheses can be fined up to the greater of $11,100 or three times the value of the benefit that should have been provided. Additionally, there may be consequences for breaching other related provisions of the Act, such as providing misleading or deceptive information regarding benefits, which can attract penalties under section 333 of the Act. These provisions underscore the importance of adherence to the rules for both insurers and policyholders to ensure the proper functioning of the private health insurance system.

Legal classification tags

Area of Law
Health Law
Insurance Law
Instrument
Regulation
Concepts
Definitions & Interpretation
Regulatory Standards
Licensing & Registration
Reporting & Disclosure Obligations

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.