Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 2)

Administered by Department of Health, Disability and Ageing

Legislation au F2017L00271 Rules Not in force Legislative Instrument

Legislation content

EXPLANATORY STATEMENT

 

Private Health Insurance Act 2007

 

Private Health Insurance (Prostheses) Amendment Rules 2017 (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 2017 (No. 2) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2017 (No. 1) (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 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 set out in the Schedule to the Private Health Insurance (Prostheses) Rules. 

The Amendment Rules vary the Principal Rules by changing the listing details of 35 billing codes in Part B of the Schedule to reflect the correct minimum benefit of the prostheses to apply from 28 March 2017, the date of commencement of the Principal Rules.

The correction to the 35 billing codes will be published by the Department on the Private Health Insurance website to enable hospitals and insurers to update their systems before the date of commencement of the Principal Rules.

The Amendment Rules commence immediately after the commencement of the Principal Rules.


Consultation

As the Amendment Rules correct errors contained in the Principal Rules, no further consultation was undertaken in relation to the Amendment Rules.

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. 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 2017 (No. 2) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2017 (No. 1) (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 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 set out in the Schedule to the Private Health Insurance (Prostheses) Rules. 

 

The Amendment Rules amend the Principal Rules by changing the listing details of 35 billing codes in Part B to reflect the correct minimum benefit of the prostheses.

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 minimum benefit payable for 35 prostheses. In each case, the correct minimum benefit is higher than the minimum benefit specified in the Principal Rules. Each of these changes has a beneficial impact on the right to health in Australia, ensuring that  igher 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. 2) amend the Private Health Insurance (Prostheses) Rules 2017 (No. 1) to correct errors identified in the original set of rules. These amendments were enacted by the Minister for Health under the authority provided by Section 333-20 of the Private Health Insurance Act 2007. The overarching aim of these amendments is to ensure compliance with the requirements set out in the Act, specifically those concerning the provision of prostheses under health insurance policies. This legislative update seeks to rectify inaccuracies in the listing of 35 billing codes pertaining to prostheses, thereby ensuring that the minimum benefits payable for these items are correctly specified and higher than those erroneously set in the initial rules. The policy objective behind these amendments is to enhance the effectiveness and fairness of private health insurance coverage related to prostheses, aligning it with the standards of health care protection envisaged by the Act. The amendments directly address a gap in the initial rules that could potentially undermine the right to health by providing inadequate coverage for certain prostheses. By increasing the minimum benefits payable for these items, the rules aim to better protect the health rights of insured individuals, ensuring they have access to necessary prostheses under their health insurance policies. The rules are compatible with human rights as they support the right to health by ensuring that private health insurance policies provide adequate coverage for essential prostheses, thereby supporting the highest attainable standard of physical and mental health.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 2) pertains to the amendment of the Private Health Insurance (Prostheses) Rules 2017 (No. 1) to correct errors that were present in the earlier rules. The rules apply to entities within the private health insurance industry, particularly those offering health insurance policies that cover hospital treatment and hospital-substitute treatment. These rules ensure compliance with Section 333-20 of the Private Health Insurance Act 2007 by mandating the correct minimum benefits for listed prostheses. The listed prostheses are identified by specific billing codes and are detailed in the Schedule to the Private Health Insurance (Prostheses) Rules. The Amendment Rules, which include changes to the listing details of 35 billing codes, are designed to ensure that the minimum benefit payable for these prostheses is correctly reflected, thus enhancing the benefits available under private health insurance policies. These rules have a national reach across Australia, applying to all private health insurers operating within the country. The rules were developed under the authority granted by the Private Health Insurance Act 2007 and are intended to take effect immediately after the commencement of the Principal Rules.

Key Provisions

The Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 2) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2017 (No. 1) (the Principal Rules) to correct errors in the Principal Rules. These amendments ensure that the minimum benefits payable for 35 prostheses are correctly specified, as outlined in the Schedule to the Private Health Insurance (Prostheses) Rules. The listed prostheses are identified by billing codes and are subject to the requirements stipulated in Item 4 of the table in subsection 72-1(2) of Part 3-3 of the Private Health Insurance Act 2007 (the Act). Specifically, these rules require that a complying health insurance policy that covers hospital treatment must provide a benefit for the provision of a listed prosthesis under specified circumstances. These circumstances include situations where a Medicare benefit is payable or other conditions set out in the Prostheses Rules. The Amendment Rules impose obligations on both health insurers and hospitals to ensure compliance with the corrected prostheses benefit details. Health insurers must update their policies to reflect the amended minimum benefits for the 35 prostheses listed, ensuring that policyholders receive the correct coverage when they need these prostheses. Hospitals, on the other hand, must align their billing practices with the updated rules to ensure they are correctly reimbursed for providing these prostheses. Insurers and hospitals are required to update their systems to reflect these changes before the date of commencement of the Principal Rules, which is 28 March 2017. Failure to comply with the Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 2) may lead to legal consequences. Although the rules do not explicitly outline specific penalties, non-compliance could result in breaches of the Private Health Insurance Act 2007. Such breaches could lead to civil or criminal penalties under the Act. For example, insurers found to be non-compliant with the Act's requirements could face fines and other enforcement actions. The maximum penalties for breaches of the Act include substantial fines for both individuals and corporations, which can significantly impact the operations and reputation of non-compliant entities. Additionally, non-compliance could result in policyholders being underpaid for necessary prostheses, which could lead to further legal disputes and regulatory scrutiny.

Legal classification tags

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

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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.