PHI 39/14

This circular issued by the Private Health Insurance Branch contains information about the Changes to the Private Health Insurance (Benefit Requirements) Rules 2011

Page last updated: 25 June 2014

Printable version of 39/14 (PDF 120 KB)

25 June 2014

Changes to the Private Health Insurance (Benefit Requirements) Rules 2011

The Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No. 2) (the Benefit Requirements Amendment Rules) were registered with the Federal Register of Legislative Instruments (FRLI) and commence on 1 July 2014 (FRLI No: F2014L00801).

These Benefit Requirements Amendment Rules amend the Private Health Insurance (Benefit Requirements) Rules 2011.

Overnight accommodation benefits and same day accommodation benefits at private hospitals and public hospitals

Increases to overnight accommodation benefits and same day accommodation benefits at private hospitals and public hospitals have been made to reflect the March 2013 to March 2014 Consumer Price Index (CPI) increase.

The Benefit Requirements Amendment Rules update the minimum benefit payable per night for patients in private hospitals in all States/Territories and shared ward accommodation at public hospitals in Victoria and Tasmania, providing that the patient is not classified as a nursing-home type patient. The following rates will apply:

Advanced surgical patient
  • first 14 days $405
  • over 14 days $281
Surgical patient or obstetric patient
  • first 14 days $376
  • over 14 days $281
Psychiatric patient
  • first 42 days $376
  • 43 – 65 days $326
  • over 65 days $281
Rehabilitation patient
  • first 49 days $376
  • 50 – 65 days $326
  • over 65 days $281
Other patients
  • first 14 days $326
  • over 14 days $281
An amendment has been made to the minimum benefit payable per night for patients in shared ward accommodation at public hospitals in the Australian Capital Territory (ACT), New South Wales (NSW), Northern Territory, Queensland, South Australia and Western Australia, providing that the patient is not classified as a nursing-home type patient. The new rates are as follows:
  • ACT $335;
  • NSW $335;
  • Northern Territory $335;
  • Queensland $341;
  • South Australia $335;
  • Western Australia $335.
New rates for minimum benefit for same-day accommodation in public hospitals and in private hospitals are implemented in each State and Territory and are as follows:
Public hospitalsBand 1Band 2Band 3Band 4
NSW$243$271$298$335
ACT$243$271$298$335
Northern Territory$243$277$322$335
Queensland$248$278$306$341
South Australia$243$277$306$335
Tasmania$236$280$325$376
Victoria$238$281$327$376
Western Australia$275$275$275$275
Band 1Band 2Band 3Band 4
Private Hospitals$210$264$322$376

Nursing-home type patients – Schedule 4

Increases were made to the minimum benefits for Nursing-Home Type Patients (NHTP) in public hospitals in South Australia and Western Australia to reflect the twice annual pension increase which occurred 20 March 2014. The following new rates will apply:
State/TerritoryMinimum benefit per night
South Australia$114.00
Western Australia$133.20
The existing rates for other states and territories remain in force and are as follows:
State/TerritoryMinimum benefit per night
New South Wales$114.05
Northern Territory$83.10
Queensland$109.00
Tasmania$133.90
Victoria$118.00
ACT$111.20

Second Tier Default Benefits – Schedule 5

The purpose of the amendments to Schedule 5 was to insert a reference to the new list of Second-tier eligible facilities compiled by the Second Tier Advisory Committee. Further information about this is available in PHI Circular 38/14.

Medicare Benefit Schedule (MBS) item numbers – Schedules 1 and 3

The Benefit Requirements Amendment Rules amend MBS items in Schedule 1 and 3 of the Private Health Insurance (Benefit Requirements) 2011. The changes are necessary to maintain consistency between the MBS item codes listed in the Principal Rules and the MBS from 1 July 2014.

Item 1 - Schedule 1, Part 2 Type A procedures, Subclause 4(3) Advanced surgical patient

Item 1 amends Schedule 1, Part 2 Type A procedures, Subclause 4(3) Advanced Surgical Patient, by removing two MBS item numbers (42659 and 42737) from Schedule 1 of the Principal Rules as these items have been removed from the MBS. Item 1 further inserts two new MBS item numbers (38273 and 38274). Item numbers 42659 and 42737 are ophthalmology items that have been made redundant as a result of the outcomes of the MSAC ophthalmology Review Stage II. Item numbers 38273 and 38274 relate to transcatheter closure of patent ductus arteriosus and ventricular septal defect as alternative techniques to open heart surgery.

Item 2 - Schedule 1, Part 2 Type A procedures, Subclause 6(3) Surgical patient

Item 2 amends Schedule 1, Part 2 Type A procedures, Clause 6 Surgical Patient, subclause (3) by removing three MBS item numbers (31518, 31521 and 31527) as these items have been removed from the MBS. Item 1 further inserts two new MBS item numbers (31519, 31525).

Item numbers 31518, 31521 and 31527 are mastectomy items, the deletion of these items and the introduction of the two new items (3519 and 31525) comes as a result of the merging of four mastectomy items into three items, by removing the gender specific terminology in the item descriptors (‘male’ or ‘female’) and replacing them with gender neutral terminology. These changes also reflect the Australian Government Guidelines on the Recognition of Sex and Gender, developed by the Attorney-General’s Department.

Item 3 – Schedule 3, Part 3 Type C procedures, Clause 8, Category 3 Therapeutic Procedures, T8

Item 3 amends Schedule 3, Part 3 Type C procedures, Clause 8, Category 3 Therapeutic Procedures, T8 of the Principal Rules by removing one MBS item number (42797).

Item number 42797 is an ophthalmology item that has also been made redundant as a result of the outcomes of the MSAC ophthalmology Review Stage II.

Item 4 – Schedule 3, Part 3 Type C procedures, Clause 8, Category 5 Diagnostic Imaging Services, I1

Item 4 amends Schedule 3, part 3 Type C procedures, Clause 8, Category 5 Diagnostic Imaging Services, I1 of the Principal Rules by removing four MBS item numbers (55044, 55045, 55731 and 55733). Item 4 further inserts four new MBS item numbers (55065, 55067, 55068 and 55069).

Item numbers 55044, 55045, 55731 and 55733 are pelvis ultrasound items. The removal of these items and the introduction of the four new items (55065, 55067, 55068 and 55069) merges the eight exiting MBS pelvis ultrasound items, by removing the gender specific terminology in the item descriptors (‘male’ or ‘female’) and replacing it with gender neutral terminology

Details of the amendments are set out in the Benefit Requirements Amendment Rules, which are available on the ComLaw website.

Changes to the Private Health Insurance (Complying Product) Rules 2010 (No. 2)

The Private Health Insurance (Complying Product) Amendment Rules 2014 (No. 5)(Complying Product Amendment Rules) were registered with the FRLI (FRLI No: F2014L00797) and commence on 1 July 2014.

These Rules amended the Private Health Insurance (Complying Product) Rules 2010 (No. 2).

The amendments update the patient contribution rates for nursing-home type patients in the Australian Capital Territory to $55.80.
State/TerritoryContribution Rates
Australian Capital Territoryfrom $53.55 to $55.80
The existing rates for other states and territories remain in force and are as follows:
State/TerritoryContribution Rates
New South Wales$55.80
Northern Territory$55.80
Queensland $55.80
Tasmania$55.80
Victoria $55.80
Western Australia$55.80
Private hospitals nationally$55.80
Details of the amendment is set out in the Complying Product Amendment Rules, which are available on the ComLaw website.

If you require further information please telephone: (02) 6289 9853/24 hr answering machine or email the enquiry to Private Health Insurance Branch.

For more information visit 2014 Private Health Insurance (PHI) Circulars.

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