Private Health Insurance (Prostheses) Amendment Rules 2018 (No.1)

Administered by Department of Health, Disability and Ageing

Legislation au F2018L00244 Rules Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Issued by the Authority of the Minister for Health

Private Health Insurance Act 2007

Private Health Insurance (Prostheses) Amendment Rules 2018 (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 2018 (No.1) (Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2018 (No.1) (the Principal Rules) to include two billing codes to Part B of the Schedule to the Principal Rules that had been omitted due to an IT database error.

 

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 in circumstances which are set out in Private Health Insurance (Prostheses) Rules. The specified conditions are those that 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 amend the Principal Rules by adding the following two billing codes and their listed benefits to Part B of the Schedule to the Principal Rules:

 

  • QHV13 – Engineered Cancellous Bone
  • QHV14 - 1g Demineralised Bone Matrix

The billing code is a reference code allocated to a listed prosthesis. The billing code facilitates hospital invoicing procedures and the payment of benefits by insurers.

In the Delegated Instruments Monitor No. 1 (2018) the Senate Regulations and Ordinances Committee raised concerns that errors in the listing of benefits on the Schedule to the Principal Rules could have the effect of increasing out-of-pocket expenses for some individuals.  The effective date of the Principal Rules is 14 March 2018.  These Amendment Rules insert the two billing codes prior to the commencement of the Principal Rules.  Therefore, no person or entity will be negatively affected by the Amendment Rules, or the IT database error.

 

Consultation

 

The affected Sponsor raised the matter following publication of the Principal Rules.  The error would negatively affect the Sponsor if not corrected prior to the commencement of the Principal Rules.

 

 

The Amendment Rules are a legislative instrument for the purposes of the Legislation Act 2003.

 

 

Authority:  Section 333-20 of the

           Private Health Insurance

Act 2007

 

 


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 2018 (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 2018 (No.1) (the Amendment Rules) amend the Private Health Insurance (Prostheses) Rules 2018 (No.1) (the Principal Rules) to include two billing codes to Part B of the Schedule to the Principal Rules that had been omitted due to an IT database error.

 

Item 4 of the table in subsection 72-1(2) of Part 3-3 of the Private Health Insurance Act 2007 (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 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 the following two billing codes and their listed benefits:

 

  • QHV13
  • QHV14

 

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 inclusion of the two items to the Schedule of the Rules as no gap prostheses or gap permitted prostheses will ensure that an insured person with appropriate cover will receive a minimum benefit for the provision of the prosthesis as hospital treatment or, where applicable hospital-substitute treatment, and:

  • the prosthesis is provided in circumstances where a medicare benefit is payable and any relevant conditions in the Rules are met; or
  • the prosthesis is provided in other circumstances specified in the Rules and any relevant conditions are met.

 

Analysis

The Rules will maintain the existing rights to health and social security by ensuring access to publicly subsidised health services which are clinically effective and cost-effective.

 

Conclusion

The Rules are compatible with human rights because they advance the protection of human rights.

Harry Rothenfluh

Assistant Secretary

Office of Health Technology Assessment

Technology Assessment and Access Division

Department of Health

 

Overview

The Private Health Insurance (Prostheses) Amendment Rules 2018 (No. 1) were enacted to address an oversight in the original Private Health Insurance (Prostheses) Rules 2018 (No. 1), which omitted two billing codes due to an IT database error. This amendment ensures that the listed prostheses now include two additional items: Engineered Cancellous Bone and 1g Demineralised Bone Matrix. The rules were introduced by the Minister for Health under the authority of section 333-20 of the Private Health Insurance Act 2007. The primary policy objective is to correct the IT database error to prevent any increase in out-of-pocket expenses for insured individuals, thereby ensuring compliance with the benefit requirements for hospital treatment as stipulated in the Act. The rules were developed in consultation with the affected private health insurer and are compatible with human rights, particularly the right to health, by ensuring equitable access to necessary prostheses.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules 2018 (No.1) applies to the Private Health Insurance (Prostheses) Rules 2018 (No.1) and is made pursuant to the authority provided under Section 333-20 of the Private Health Insurance Act 2007. These Amendment Rules specifically address an IT database error that omitted two billing codes from the Principal Rules, thereby ensuring that insured individuals receive the correct benefits for specified prostheses. The amendment applies to entities providing private health insurance, including health insurers, hospitals, and medical practitioners, as well as insured individuals who are eligible for prostheses covered under a complying health insurance policy. The rules are designed to ensure that there are no gaps in coverage for certain prostheses, thus preventing any increase in out-of-pocket expenses for insured individuals. The amendment is effective as of the commencement of the Principal Rules, ensuring that the correction does not negatively impact any person or entity.

Key Provisions

The Private Health Insurance (Prostheses) Amendment Rules 2018 (No. 1) amend the Private Health Insurance (Prostheses) Rules 2018 (No. 1) to rectify an oversight in the listing of prostheses. Specifically, the Amendment Rules add two billing codes, QHV13 and QHV14, which were omitted from Part B of the Schedule to the Principal Rules due to an IT database error. This inclusion ensures that all required prostheses are accurately listed and available for compliance with the Act's requirements. Section 333-20 of the Private Health Insurance Act 2007 allows the Minister to make these amendments to ensure the rules accurately reflect the intended legislative framework. The Amendment Rules impose specific obligations on health insurance providers and beneficiaries. Health insurers must ensure that their policies comply with the updated list of prostheses, including the newly added codes QHV13 and QHV14. Beneficiaries, in turn, must be aware of their rights to receive benefits for these prostheses under the specified conditions outlined in the Act. The rules necessitate that any hospital treatment policy, including those that cover hospital-substitute treatment, must provide benefits for these listed prostheses when provided under the circumstances where a Medicare benefit is payable or in other specified conditions. Failure to comply with the requirements set out in the Amendment Rules may result in various consequences. Although the Amendment Rules themselves do not specify explicit penalties, non-compliance with the overarching Private Health Insurance Act 2007 can lead to civil or criminal penalties. These penalties could include fines or imprisonment, depending on the severity and intent of the breach. The Act allows for enforcement actions to be taken against insurers who do not adhere to the stipulated benefit requirements, ensuring that insured individuals receive the appropriate coverage for listed prostheses.

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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.