Private Health Insurance (Prostheses) Amendment Rules (No. 2) 2022

Administered by Department of Health, Disability and Ageing

Legislation au F2022L01012 Rules Not in force Legislative Instrument

Legislation content

EXPLANATORY STATEMENT

Private Health Insurance Act 2007

 

Private Health Insurance (Prostheses) Amendment Rules (No. 2) 2022

 

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.

 

Subsection 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) Rules (Prostheses Rules) are made for the purposes of subsection 333-20(1) of the Act. Listed prostheses and their minimum benefits are set out in the Schedule to the Prostheses Rules. The list of prostheses in the Schedule is commonly referred to as the Prostheses List.

 

The Schedule to the Prostheses Rules has three parts:

 

  • Part A – Prostheses;
  • Part B – Human Tissues;
  • Part C – Other Prostheses.

 


The purpose of the Private Health Insurance (Prostheses) Amendment Rules (No. 2) 2022 (the Amending Rules) is to:

 

  • add 2 new Prostheses List billing codes to Part A of the Schedule following successful applications;
  • correct the benefit for billing code ZA110 in Part A of the Schedule;
  • move 493 billing codes for the general use items from Part A to the newly established Part D of the Schedule.

 

The new Part D of the Schedule will list billing codes for devices that have been identified by the Clinical Implementation Reference Group (CIRG) as general use items. The CIRG is an independent group of clinicians who provide advice to the Australian Government Department of Health and Aged Care on measures being implemented as part of the Prostheses List reforms.

 

The general use items are scheduled to be removed from the Prostheses List on 1 July 2023, when bundling arrangements are intended to be implemented. Removal of the general use items from the Prostheses List does not mean removing these products from the market, i.e. it is expected they will continue to be available for use by doctors under a different funding agreement with no clinical implications or adverse outcomes to patients.

 

Consultation

 

The Amending Rules have been made following consultation with the sponsors of the new prostheses as part of the assessment of their applications. Changes related to the Prostheses List Part D aim to provide clarity regarding some aspects of the reforms, but do not have any material effect on the listing of the prostheses.

 

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

 

The Prostheses Rules commence on 1 August 2022.

 

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

ATTACHMENT

 

Provision by provision description of the Private Health Insurance (Prostheses) Amendment Rules (No. 2) 2022 (Amending Rules)

 

Rule 1 Name

 

Rule 1 provides that the title of the Amending Rules is the Private Health Insurance (Prostheses) Amendment Rules (No. 2) 2022.

 

Rule 2 Commencement

 

Rule 2 provides that the Amending Rules commence on 1 August 2022.

 

Rule 3 Authority

 

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

 

Rule 4  Schedules

 

Rule 4 provides that each instrument that is specified in Schedule 1 to the Amending Rules is amended or repealed as set out in the applicable items to the Schedule, 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. 2) 2022

 

Item 1 repeals Schedule 1, Part 1 – Prostheses List – Part A table and replaces it with updated table.

 

Item 2 adds Schedule 1, Part 4 – Prostheses List – Part D.


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. 2) 2022
 

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 Private Health Insurance (Prostheses) Rules (No. 2) 2022 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. 2) 2022 (the Amending Rules) amend the Private Health Insurance (Prostheses) Rules (No. 2) 2022 (the Prostheses Rules) by:

  • adding 2 new Prostheses List billing codes to Part A of the Schedule following successful applications;
  • correcting the benefit for billing code ZA110 in Part A of the Schedule;
  • moving 493 billing codes for the general use items from Part A to the newly established Part D of the Schedule.

 

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

The addition of billing codes and the correction of benefit will ensure that an insured person has access to private health insurance benefits for prostheses that have been assessed as clinically and cost effective. Moving devices from Part A to Part D of the Schedule will ensure that insured persons will continue to have access to private health insurance benefits while alternative funding arrangements are being negotiated and implemented. These changes will impact positively on the right to health of insured persons.

 


Conclusion

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

 

Elizabeth Flynn

Assistant Secretary

Prostheses List Reform Taskforce

Technology Assessment and Access Division

Health Resourcing Group

Department of Health

 

Overview

The Private Health Insurance (Prostheses) Amendment Rules (No. 2) 2022 were enacted to amend the existing Private Health Insurance (Prostheses) Rules (No. 2) 2022 under section 333-20 of the Private Health Insurance Act 2007. The 2007 Act sets out benefit requirements for complying health insurance policies, including the provision of prostheses listed in the Private Health Insurance (Prostheses) Rules. The amendment rules address the need to update the Prostheses List to ensure that insured individuals have access to clinically and cost-effective prostheses, correct any discrepancies in benefits, and prepare for the implementation of bundling arrangements by reclassifying general use items. These rules were made by the Minister for Health and Aged Care following consultation with stakeholders and aim to enhance the right to health by providing clarity and ensuring continued access to necessary prostheses. The Amending Rules were introduced to refine the Prostheses List, which is integral to the operation of the private health insurance system in Australia. The rules provide for the addition of new billing codes, correction of benefits, and reclassification of certain items to accommodate the Prostheses List reforms. The introduction of these rules ensures compliance with the legislative intent to maintain and improve the quality and accessibility of health services, thereby supporting the overarching policy objective of the 2007 Act to provide equitable health insurance coverage. The legislative instrument is compatible with human rights, particularly the right to health, by ensuring access to appropriate and quality health care services.

Scope and Application

The Private Health Insurance (Prostheses) Amendment Rules (No. 2) 2022 applies to entities and individuals involved in the private health insurance sector, specifically those offering health insurance policies that cover hospital treatment and prosthesis provision. The Act operates within the Commonwealth jurisdiction and affects all health insurers authorised to operate in Australia. The amendment rules are an extension of the Private Health Insurance Act 2007, which mandates the listing of prostheses for which benefits must be provided under complying health insurance policies. The Act includes specific exclusions and thresholds for prostheses listings, which are outlined in the Prostheses Rules and subject to amendment through subordinate instruments such as the Amending Rules. These amendments include the addition of new billing codes, correction of existing benefits, and the reorganisation of general use items into a new category, all of which are intended to improve access to necessary prostheses under private health insurance policies. The scope of the Prostheses Rules and the Amending Rules ensures that the right to health, as recognised under article 12 of the International Covenant on Economic, Social and Cultural Rights, is upheld by providing clarity and access to necessary prostheses. The changes introduced by the Amending Rules are designed to maintain and enhance the quality of health care by ensuring that insured persons can access appropriate and cost-effective prostheses. This legislative framework is essential for maintaining the standards and provisions required by the Private Health Insurance Act 2007, ultimately aiming to protect and advance the health rights of insured individuals within Australia.

Key Provisions

The Private Health Insurance (Prostheses) Amendment Rules (No. 2) 2022 (the Amending Rules) are a legislative instrument designed to amend the Private Health Insurance (Prostheses) Rules (No. 2) 2022 (the Prostheses Rules) under section 333-20 of the Private Health Insurance Act 2007. The Amending Rules, which came into effect on 1 August 2022, introduce several key changes to the Prostheses Rules. Firstly, they add two new Prostheses List billing codes to Part A of the Schedule, following successful applications. Secondly, they correct the benefit for billing code ZA110 in Part A of the Schedule. Lastly, they move 493 billing codes for general use items from Part A to a newly established Part D of the Schedule. The purpose of these amendments is to ensure that insured persons have access to private health insurance benefits for prostheses that have been assessed as clinically and cost-effective, while also providing clarity regarding the Prostheses List reforms. The Amending Rules impose obligations on the parties involved, including the Minister for Health and Aged Care, insurance providers, and healthcare providers. The Minister is responsible for making the Amending Rules in accordance with the powers conferred by the Private Health Insurance Act 2007. Insurance providers must ensure that their policies comply with the updated Prostheses List, including the addition of new billing codes, the correction of benefits, and the reclassification of general use items. Healthcare providers must also be aware of these changes to ensure that they can bill for prostheses services correctly and that their patients can access the benefits provided by their health insurance policies. There are no specific offences or penalties outlined in the Amending Rules themselves. However, failure to comply with the Private Health Insurance Act 2007 or the amended Prostheses Rules may result in civil or criminal consequences. For example, insurance providers that do not adhere to the benefit requirements outlined in the Act or the Prostheses Rules may be subject to financial penalties, enforcement actions, or other regulatory measures by the Australian Prudential Regulation Authority. Similarly, healthcare providers that bill for services not covered by the Prostheses List or that do not follow the correct billing codes may face financial penalties or other consequences. The specific penalties and consequences for non-compliance with the Private Health Insurance Act 2007 and the Prostheses Rules will depend on the nature and severity of the breach.

Legal classification tags

Area of Law
Health Law
Instrument
Regulation
Concepts
Definitions & Interpretation
Reporting & Disclosure Obligations
Regulatory Standards

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.