PHI 63/14

This circular issued by the Private Health Insurance Branch contains information on Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No. 5) Changes to the Private Health Insurance (Benefit Requirements) Rules 2011

Page last updated: 31 October 2014

Printable version of PHI 63/14 (PDF 125 KB)
31 October 2014

Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No. 5)
Changes to the Private Health Insurance (Benefit Requirements) Rules 2011


The Private Health Insurance (Benefit Requirements) Amendment Rules 2014 (No. 5) (the Amendment Rules) were registered with the Federal Register of Legislative Instruments (FRLI). Sections 1, 2, 4, 5, 6 and 7 of the Amendment Rules commence on 1 November 2014 while section 3 commences on 1 January 2015. (FRLI No: F2014LXXXXX).
These Benefit Requirements Amendment Rules amend the Private Health Insurance (Benefit Requirements) Rules 2011.

Medicare Benefit Schedule (MBS) item numbers – Schedule 1

The Amendment Rules insert one new MBS item in Schedule 1 of the Private Health Insurance (Benefit Requirements) 2011.

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

Item 1 amends Schedule 1, Part 2 Type A procedures, Clause 6 Surgical patient, subclause (3) of the Principal Rules by inserting MBS item number 35534.

Item number 35534 will clarify the clinical conditions for vulvoplasty in item 35533 by splitting it into two separate items (35533 and 35534) to better articulate the clinical conditions to which the service applies.

Medicare Benefit Schedule (MBS) item numbers – Schedule 3

The Amendment Rules inserts 47 new MBS items and removes seven MBS items from Schedule 3 of the Private Health Insurance (Benefit Requirements) 2011.

Item 2 – Schedule 3, Part 2 Type B procedures, Clause 5 Non-band specific Type B day procedures, subclause (1)

Item 2 amends Schedule 3, Part 2 Type B procedures, Clause 5 Non-band specific Type B day procedures, subclause (1) by inserting one new MBS item number (18379).

New item 18379 will be introduced for the intravesical injection of Botox® for the treatment of certain patients with urinary incontinence due to idiopathic overactive bladder.

This change will be effective from 1 November 2014 and subsequently needs to be inserted into the Principal Rules.

Item 3 – Schedule 3, Part 2 Type B procedures, Clause 5 Non-band specific Type B day procedures, subclause (1)

Item 3 amends Schedule 3, Part 2 Type B procedures, Clause 5 Non-band specific Type B day procedures, subclause (1) by inserting 27 new MBS item numbers.

Amendments are being made to the Health Insurance (Diagnostic Imaging Services Table) Regulations to implement the 2014-15 Budget measure, ‘MBS – revised capital sensitivity provisions for diagnostic imaging equipment’, which is to take effect on 1 January 2015, resulting in the addition of 27 new (NK) angiography items where corresponding (K) items are referenced. Subsequently these items are being inserted into the Principal Rules.

Item 4 – Schedule 3, Part 3, Type C procedures, Clause 8 Interpretation, Category 5 Diagnostic Imaging Services, I5

Item 4 amends Schedule 3, Part 3 Type C procedures, Clause 8 Interpretation, Category 5 Diagnostic Imaging Services, I5 of the Principal Rules by inserting six new MBS item numbers (63740, 63741, 63743, 63744, 63746 and 63747).

Amendments are being made to the DIST to insert six new MBS items (63740, 63741, 63743, 63744, 63746, and 63747) that will be listed for Magnetic Resonance Imaging for evaluation of pelvic sepsis and fistulising perianal Crohn disease and evaluation of known or suspected complications in small bowel Crohn disease. These changes will be effective from 1 November 2014. Subsequently the abovementioned items need to be inserted and removed from the Principal Rules.

Item 5 – Schedule 3, Part 3, Type C procedures, Clause 8 Interpretation, Category 3 Therapeutic Procedures, T11

Item 5 amends Schedule 3, Part 3 Type C procedures, Clause 8 Interpretation, Category 3 Therapeutic Procedures, T11 of the Principal Rules by removing two MBS item numbers (18356 and 18358).

Amendments are being made to fourteen items listed in the Health Insurance (General Medical Services Table) Regulations (GMST) to reflect a more simplified item structure. These amendments will result in the removal of items 18356 and 18358 from the GMST which subsequently require removal from the Principal Rules.

Item 6 – Schedule 3, Part 3 Type C procedures, Clause 8, Interpretation, Category 6 – Pathology services, P2

Item 6 amends Schedule 3, Part 3 Type C procedures, Clause 8, Interpretation, Category 6 – Pathology services, P2 of the Principal Rules by removing four MBS item numbers (66599, 66602, 66608 and 66609) and inserting nine new MBS item numbers (66833, 66834, 66835, 66836, 66837, 66838, 66839, 66840 and 66841).

Amendments are being made to the Health Insurance (Pathology Services Table) Regulations (PST) to insert eight new items to provide a more targeted approach to existing arrangements for Vitamin D, B12, and Folate, as recommended by the Medical Services Advisory Committee (MSAC). As a consequence, the current items for Vitamin D, B12, and Folate (66608, 66609, 66599, and 66602) will be removed from the PST. Further, a new item (66841) is also being listed in the PST for quantitation of HbA1c for the diagnosis of diabetes mellitus in patients with undiagnosed diabetes who are considered at high risk of the disease.

These changes will be effective from 1 November 2014. Subsequently the abovementioned items need to be inserted and removed from the Principal Rules.

Item 7 – Schedule 3, Part 3 Type C procedures, Clause 8, Interpretation, Category 6 – Pathology services, P7

Item 7 amends Schedule 3, Part 3 Type C procedures, Clause 8, Interpretation, Category 6 – Pathology services, P7 of the Principal Rules by removing one MBS item number (73328) and inserting four new MBS item numbers (73336, 73337, 73339 and 73340).

Amendments are being made to the PST to insert two current MBS items (73336 and 73337) to reflect current MBS pathology services. Subsequently item 73328 is being removed from the PST as it is made redundant by the inserted items.

Further amendments are being made to the PST to insert two new MBS items (73339 and 73340) to cover the use of diagnostic and predictive testing for mutations in the RET gene. These items would be for patients with symptoms of multiple endocrine neoplasia type II (MEN2) and unaffected relatives of a patient with a documented RET mutation to determine the risk of disease. Subsequently the abovementioned items need to be respectively inserted and removed from the Principal Rules.

These changes will be effective from 1 November 2014. Subsequently the abovementioned items need to be inserted and removed from the Principal Rules.

Details of the amendments are set out in the 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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