Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 1)

Administered by Department of Health, Disability and Ageing

Legislation au F2017L00089 Not in force Legislative Instrument

Legislation content

EXPLANATORY STATEMENT

 

Private Health Insurance Act 2007

 

Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 1)

 

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 2017 (No. 1) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2016 (No. 4) (the Principal Rules) to correct 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 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 vary the Principal Rules, correcting errors to billing codes and their listing details made where benefit reductions for 2,439 devices were auto generated and listed in the Private Health Insurance (Prostheses) Amendment Rules 2016 (No. 4) (2016 Amendment Rules). The undiscovered system error reverted some billing codes back to their original name, description, size or changed their suffix. In total, 391 billing codes require correction.

These errors are corrected by the Amendment Rules to ensure that the benefit reductions as listed in the 2016 Amendment Rules take effect and that these devices remain eligible for benefits from insurers.  The correction to the 391 billing codes is to be published as soon as possible to enable hospitals and insurers to update their systems before the date of commencement.

The Amendment Rules commence immediately after the commencement of the Private Health Insurance (Prostheses) Amendment Rules 2016 (No. 4).


Consultation

In accordance with section 17 of the Legislation Act 2003, the Department and Government consulted widely with the sponsors and other affected stakeholders regarding prostheses benefits, including holding an Industry Working Group on Private Health Insurance Prostheses Reform (the Industry Working Group) in relation to the 2016 Amendment Rules.

As the Amendment Rules correct errors contained in the 2016 Amendment Rules, no further consultation was undertaken.

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 Legislation 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 2017 (No. 1)

 

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 2017 (No. 1) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2016 (No. 4) (the Principal Rules) to correct errors in the Principal Rules as a result of the changes made by the Private Health Insurance (Prostheses) Amendment Rules 2016 (No. 4) (2016 Amendment 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 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 replacing Part A of the Schedule with a new Part A and correct the listing details of 391 billing codes that were incorrectly listed in the 2016 Amendment Rules. 

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 correct the billing code of 391 prostheses.  Each of these changes has a beneficial impact on the right to health in Australia, ensuring that minimum benefits, or higher minimum benefits, are required to be paid for the provision of these prostheses under private health insurance policies covering hospital treatment, where relevant conditions are met.  

 

Conclusion

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

 

Tracey Duffy

Assistant Secretary

Private Health Insurance Branch

Medical Benefits Division

Department of Health

 

Overview

The Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 1) were enacted to address the inaccuracies in the Private Health Insurance (Prostheses) Rules 2016 (No. 4) that were identified due to an error in the system generating auto benefits. These amendment rules were made under the authority provided by Section 333-20 of the Private Health Insurance Act 2007, with the aim of ensuring that the prostheses benefits remain consistent with the policy objectives of the Act. The rules were developed following consultations with stakeholders and the sponsors of the Act, ensuring that the changes would be beneficial to both insurers and patients. The rules amend the Principal Rules to correct errors in the listing details of 391 billing codes, ensuring that the benefits for the provision of prostheses are accurately reflected and that the right to health is upheld. The Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 1) aim to correct the errors in the 2016 Amendment Rules that affected the billing codes and their listing details for prostheses. These rules were developed by the Department of Health and are consistent with the policy objective of ensuring that the private health insurance system provides adequate benefits for necessary medical procedures. The rules correct the listing details of 391 billing codes, ensuring that the benefits for prostheses are accurately reflected and that the right to health is upheld. The rules also ensure that the benefits remain consistent with the policy objectives of the Act and the right to health.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 1) amend the Private Health Insurance (Prostheses) Rules 2016 (No. 4) to correct errors resulting from the Private Health Insurance (Prostheses) Amendment Rules 2016 (No. 4). These Amendment Rules apply to entities involved in the private health insurance sector in Australia, specifically those that provide health insurance policies covering hospital treatment and hospital-substitute treatment. The rules ensure compliance with the requirements of the Private Health Insurance Act 2007, specifically the provision of benefits for listed prostheses under specified conditions. These conditions include situations where a Medicare benefit is payable or other circumstances outlined in the Act. The Amendment Rules address errors in billing codes and listing details of 391 prostheses, ensuring that benefit reductions are correctly implemented and that these devices remain eligible for benefits from insurers. The rules are designed to take effect immediately after the commencement of the 2016 Amendment Rules, with the aim of allowing hospitals and insurers to update their systems before the rules come into force.

Key Provisions

The Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 1) (Amendment Rules) primarily serve to correct errors identified in the Private Health Insurance (Prostheses) Rules 2016 (No. 4) (Principal Rules). These corrections are vital for ensuring that listed prostheses remain eligible for benefits under private health insurance policies. Specifically, the Amendment Rules address issues related to the incorrect listing of 391 billing codes, which were erroneously altered due to a system error during the implementation of the 2016 Amendment Rules. By rectifying these billing codes, the Amendment Rules aim to restore the intended benefit reductions and ensure compliance with the requirements outlined in Item 4 of subsection 72-1(2) of Part 3-3 of the Private Health Insurance Act 2007. This amendment ensures that hospitals and insurers can correctly process claims for prostheses, maintaining the integrity of the private health insurance system. The Amendment Rules impose specific obligations on parties involved in the provision and administration of private health insurance. Insurers must ensure that their policies accurately reflect the corrected billing codes for listed prostheses, thereby guaranteeing that policyholders receive the correct benefits for specified prostheses. Hospitals and other medical service providers must also update their records and billing practices to align with the corrected information, ensuring that claims for prostheses are processed correctly and efficiently. By doing so, both insurers and providers help uphold the standards set by the Act and the Principal Rules. Non-compliance with the Amendment Rules could potentially lead to significant consequences, although the document does not explicitly detail specific penalties for breaches. However, it is reasonable to infer that any failure to adhere to the corrected billing codes could result in incorrect payment of benefits, disputes between insurers and policyholders, and potential legal challenges. Insurers that do not update their policies to reflect the corrected information may face claims from policyholders who do not receive the benefits they are entitled to. Additionally, hospitals and providers who fail to update their billing systems may encounter payment issues or be subject to audits by regulatory authorities. The overarching objective of the Amendment Rules is to ensure that the integrity and efficacy of the private health insurance system are maintained, thereby protecting the rights of policyholders to receive appropriate benefits for prostheses. The human rights implications of the Amendment Rules are centred on the right to health, as outlined in article 12(1) of the International Covenant on Economic, Social and Cultural Rights (ICESCR). By correcting the billing codes for 391 prostheses, the Amendment Rules enhance the ability of individuals to access necessary medical treatments and devices. This ensures that the highest attainable standard of health is supported under private health insurance policies, thereby advancing the right to health in Australia. The Amendment Rules demonstrate compatibility with human rights by promoting a health protection system that provides equality of opportunity for people to enjoy better health outcomes.

Legal classification tags

Area of Law
Health Law
Instrument
Regulation
Concepts
Definitions & Interpretation
Correction of Errors
Right to Health

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.