Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 3)

Administered by Department of Health, Disability and Ageing

Legislation au F2017L00484 Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Private Health Insurance Act 2007

 

Private Health Insurance (Prostheses) Amendment Rules 2017 (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 2017 (No. 3) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2017 (No. 1) (the Principal Rules) to increase the minimum benefit payable for one prosthesis listed in the Principal Rules and to add eight additional prostheses to 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, increasing the minimum benefit payable in respect of one billing code and adding eight new billing codes for devices which have been approved for inclusion in the Principal Rules.

The Amendment Rules commence 1 May 2017.


Consultation

As the Amendment Rules increase the minimum benefit of an item in the Principal Rules and add billing codes, 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. 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 2017 (No. 3) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2017 (No. 1) (the Principal Rules) to increase the minimum benefit payable for one prosthesis listed in the Principal Rules and to add eight additional prostheses to 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 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 eight new billing codes to Part A of the Schedule, and increasing the minimum benefit for one item in Part B of the Schedule. 

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 increase the minimum benefit payable for one prosthesis and introduce  eight new billing codes.  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. 3) were enacted to amend the Private Health Insurance (Prostheses) Rules 2017 (No. 1) to increase the minimum benefit payable for one prosthesis and add eight additional prostheses to the list of those covered under private health insurance policies. This legislative instrument addresses a gap in the provision of adequate coverage for certain prostheses under private health insurance, thereby enhancing the quality of health care services available to Australians. Enacted by the Australian Government, the policy objective behind these rules is to ensure compliance with the requirements of the Private Health Insurance Act 2007, specifically addressing the benefits for prostheses under hospital treatment and hospital-substitute treatment. These amendments aim to improve access to necessary medical devices and align the benefits with current medical standards and practices.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 3) amends the Private Health Insurance (Prostheses) Rules 2017 (No. 1) to enhance the minimum benefits payable for specific prostheses and to include eight additional prostheses under the scope of the Private Health Insurance Act 2007. These Amendment Rules apply to entities providing private health insurance policies in Australia, specifically targeting those that cover hospital treatment and hospital-substitute treatment. The rules ensure compliance with the Act's requirements by specifying the circumstances under which benefits for listed prostheses must be provided, particularly when a Medicare benefit is payable or under other conditions outlined in the Principal Rules. The changes are effective from 1 May 2017 and are designed to improve the quality and accessibility of health care services by ensuring that certain prostheses are covered under private health insurance policies, thereby supporting the right to health as recognised under international human rights instruments.

Key Provisions

The Private Health Insurance (Prostheses) Amendment Rules 2017 (No. 3) (Amendment Rules) introduce specific changes to the Private Health Insurance (Prostheses) Rules 2017 (No. 1) (Principal Rules). Most notably, the Amendment Rules increase the minimum benefit payable for one listed prosthesis and add eight new prostheses to the Principal Rules (sections 3 and 4). These changes are intended to ensure that private health insurance policies covering hospital treatment provide adequate benefits for certain prostheses, particularly in circumstances where a Medicare benefit is payable or other specified conditions are met (subsection 72-1(2) of Part 3-3 of the Private Health Insurance Act 2007). These changes impose obligations on private health insurers to comply with the updated minimum benefits for the specified prostheses, as outlined in the Amendment Rules. Insurers must ensure that their policies cover the increased benefits for the relevant prosthesis and include the new prostheses in their coverage where applicable. This involves updating policy documentation and ensuring that policyholders are informed of the changes to the benefits provided. Failure to comply with these obligations could result in non-compliance with the requirements of the Private Health Insurance Act 2007. Breaches of the provisions in the Amendment Rules may result in enforcement actions by the relevant authorities. Although the explanatory statement does not detail specific penalties for non-compliance, breaches of the Private Health Insurance Act 2007 can lead to substantial fines, enforcement actions, or other regulatory measures. The severity of the consequences depends on the nature and extent of the non-compliance, but the overarching objective is to ensure that private health insurers adhere to the statutory requirements designed to protect policyholders’ rights to adequate health care coverage.

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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.