Private Health Insurance (Prostheses) Amendment Rules (No. 1) 2020

Administered by Department of Health, Disability and Ageing

Legislation au F2020L00203 Rules Not in force Legislative Instrument

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EXPLANATORY STATEMENT

Private Health Insurance Act 2007

 

Private Health Insurance (Prostheses) Amendment Rules (No. 1) 2020

 

Authority

 

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.

 

In addition to the power to make this instrument under section 333-20 of the Act, subsection 33(3) of the Acts Interpretation Act 1901 provides that where an Act confers a power to make, grant or issue any instrument of a legislative or administrative character (including rules, regulations or by-laws), the power shall be construed as including a power exercisable in the like manner and subject to the like conditions (if any) to repeal, rescind, revoke, amend, or vary any such instrument.

 

Section 72-10(6) of the Act provides that the Private Health Insurance (Prostheses) Rules may set out listing criteria that must be satisfied in order for an application for a prosthesis to be listed to be granted.

 

Background

 

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. Under item 4 of that table 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 in other circumstances which may be set out in the Private Health Insurance (Prostheses) Rules. The specified conditions are any that may be set out in the Private Health Insurance (Prostheses) Rules.

 

If the complying health insurance policy also covers hospital-substitute treatment, under item 4 of the table in subsection 72-1(2) of Part 3-3 of the Act the same requirements apply.

 

Purpose

 

The Private Health Insurance (Prostheses) Amendment Rules (No. 1) 2020 (Amending Rules) correct errors for three billing codes in Schedule 1, part 1, Prostheses List – Part A:

 

  • WR003, reapply the suffix, that was incorrectly removed
  • WR004, reapply the suffix, that was incorrectly removed
  • DE649, remove the condition, that was incorrectly included.

 

Consultation

 

The Amending Rules have been made following agreement with the sponsors, Wright Medical Australia and Device Technologies Australia Pty Ltd.

 

Details of the Amending Rules are set out in the Attachment.

The Amending Rules commence immediately following the commencement of Private Health Insurance (Prostheses) Rules (No. 1) 2020.

 

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

ATTACHMENT 1

 

Provision by provision description of the Private Health Insurance (Prostheses) Amendment Rules (No. 1) 2020

 

Section 1 – Name

 

Section 1 provides for the Amending Rules to be referred to as the Private Health Insurance (Prostheses) Amendment Rules (No. 1) 2020.

 

Section 2 – Commencement

 

Section 2 provides that the Amending Rules commence immediately following the commencement of Private Health Insurance (Prostheses) Rules (No. 1) 2020.

 

Section 3 – Authority

 

Section 3 provides that the Amending Rules are made under item 4 of the table in section 333‑20 of the Private Health Insurance Act 2007.

 

Section 4 – Schedules

 

Section 4 provides that each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.

 

Schedule 1 – Amendments

 

Private Health Insurance (Prostheses) Rules (No. 1) 2020

 

Correct the suffix in Part A of the Prostheses List for two prostheses, being the prostheses with billing codes WR003 and WR004.

 

Remove the condition in Part A of the Prostheses List for one prostheses, being the prostheses with billing codes DE649.

 

 

 

 


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 (No. 1) 2020
 

This 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 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. Under item 4 of that table there must be a benefit for the provision of a prosthesis, of a kind listed in 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 in other circumstances which may be set out in Private Health Insurance (Prostheses) Rules. The specified conditions are any that may be set out in Private Health Insurance (Prostheses) Rules. If the complying health insurance policy also covers hospital-substitute treatment, under item 4 of the table in subsection 72-1(2) of Part 3-3 of the Act the same requirements apply.

 

The Private Health Insurance (Prostheses) Rules (No. 1) 2020 (Prostheses Rules) were made for the purposes of section 333-20 of the Act. Listed prostheses and their minimum benefits are set out in the Schedule to the Rules.  The list of prostheses in the Schedule is commonly referred to as the Prostheses List.

 

The Private Health Insurance (Prostheses) Amendment Rules (No.1) 2020 (the Amending instrument) amends the Prostheses Rules by replacing the suffix for two prostheses and removing the condition for another in ‘Part 1 – Prostheses List – Part A’ of Schedule 1.

 

Human rights implications

This instrument engages article 12 of the International Covenant on Economic Social and Cultural Rights (ICESCR), specifically the right to health.

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 ICESCR. Whilst the UN Committee on Economic Social and Cultural Rights 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. In addition, the right to health must meet certain key requirements, including that health care must be scientifically and medically appropriate and of good quality.

Analysis

Two prostheses will now reflect the correct benefit and one prostheses will not have a condition.

 

Conclusion

The Amending instrument is compatible with human rights because it enables advances in the protection of human rights, in particular the right to health.

 

Debbie Hurlbut

Acting Assistant Secretary

Office of Health Technology Assessment

Technology Assessment and Access Division

Department of Health

 

Overview

The Private Health Insurance (Prostheses) Amendment Rules (No. 1) 2020 was enacted to amend the Private Health Insurance (Prostheses) Rules (No. 1) 2020, which were made under section 333-20 of the Private Health Insurance Act 2007. This legislation addresses the need to correct specific errors in billing codes for prostheses listed under the Act, ensuring that the benefits associated with certain prostheses are accurately reflected in the Prostheses List. The purpose of these amendments is to rectify inaccuracies that could affect the provision of private health insurance for prostheses, thereby ensuring that patients receive the appropriate benefits as intended by the Act. The rules were enacted by the Commonwealth of Australia and are intended to support the policy objective of maintaining an accurate and reliable Prostheses List that aligns with the standards and conditions set out in the Private Health Insurance Act 2007.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules (No. 1) 2020 applies to entities and individuals involved in the provision and regulation of private health insurance in Australia, particularly those administering policies that cover hospital treatment or hospital-substitute treatment. The rules amend the Prostheses Rules by correcting errors in the billing codes for certain prostheses listed under Schedule 1, Part 1, Prostheses List – Part A. This adjustment ensures that the correct suffix is applied to prostheses WR003 and WR004, and removes an incorrectly included condition for prosthesis DE649. These amendments ensure that the rules governing the provision of prostheses align with the intended legislative intent and the provisions set out in the Private Health Insurance Act 2007. The Amending Rules are a legislative instrument under the Legislation Act 2003, and they are made pursuant to section 333-20 of the Private Health Insurance Act 2007, which allows the Minister to establish rules governing prostheses. The Amending Rules correct specific errors in the initial Prostheses Rules (No. 1) 2020, which were made to set out listing criteria for prostheses to be covered under private health insurance policies. These rules apply nationally and are designed to ensure that the benefits and conditions associated with listed prostheses are accurately reflected, thereby supporting the provision of quality health care services as required by the Act.

Key Provisions

The main operative sections of the Private Health Insurance (Prostheses) Amendment Rules (No. 1) 2020 (Amending Rules) are designed to correct specific errors in the Private Health Insurance (Prostheses) Rules (No. 1) 2020. These corrections pertain to three billing codes within the Prostheses List – Part A. Specifically, section 4 of Schedule 1 of the Amending Rules rectifies the suffix for two prostheses (WR003 and WR004) that was incorrectly removed, and it removes a condition from another prosthesis (DE649) that was incorrectly included. These amendments ensure that the Prostheses List accurately reflects the intended benefits and conditions associated with each prosthesis. The obligations and requirements imposed by these rules primarily concern the entities responsible for maintaining and updating the Prostheses List. The Amending Rules mandate precise and accurate listing criteria for prostheses covered under private health insurance policies, ensuring that the benefits and conditions associated with each listed prosthesis are correctly applied. This is essential for maintaining the integrity of the Private Health Insurance Act 2007 and ensuring that consumers receive the benefits they are entitled to under their health insurance policies. While the Amending Rules themselves do not explicitly outline offences, penalties, or consequences for breaches, any non-compliance with the Private Health Insurance Act 2007 or its associated rules could result in civil or criminal penalties. Under the Act, non-compliance with listing criteria or other requirements could lead to financial penalties, enforcement actions by the Australian Competition and Consumer Commission, or other regulatory measures. The severity of penalties would depend on the nature and extent of the breach, but could include substantial fines and other sanctions. In summary, the Amending Rules focus on correcting specific errors within the Prostheses List to ensure that the benefits and conditions for listed prostheses are accurately represented. This amendment is crucial for upholding the standards set by the Private Health Insurance Act 2007 and ensuring that consumers receive appropriate coverage for their health needs.

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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.