PHI 31/20 Rules changes 1 May 2020

Private health insurance announcement.

Date published:
PHI circular
PHI circular type:
PHI announcement
Health sector

Minimum accommodation benefit requirements and clinical category changes

The Private Health Insurance Legislation Amendment Rules (No.3) 2020 (the Amendment Rules) were registered on the Federal Register of Legislation on 30 April 2020 and commenced on 1 May 2020.

The Amendment Rules amend the Private Health Insurance (Benefit Requirements) Rules 2011 (the Benefit Requirement Rules) and the Private Health Insurance (Complying Product) Rules 2015 (the Complying Product Rules).

The amendments reflect, and implement into private health delegated legislation, the 1 May 2020 changes to the Medicare Benefits Schedule (MBS) under the General Medical, Pathology, and Diagnostic Imaging services tables (GMST, PST, DIST) of the Health Insurance Act 1973. Details on the full list of changes to the MBS, including the latest fact sheets and quick reference guides, are available at MBS online, and include:

  • anaesthesia items with age identifiers
  • breast biopsy items as recommended by the MBS Taskforce
  • colonoscopy item clarifications
  • new item 42504 for micro-bypass glaucoma surgery (MBGS) standalone procedure (see note)
  • new item 37226 for prostate MRI under MRI guidance
  • schedule fee increase for items 37207 and 37208
  • changes to subgroup descriptors in Category 5 Diagnostic Imaging Services Group 5 Magnetic Resonance Imaging
  • ultrasound, computed tomography, diagnostic radiology, nuclear medicine imaging and magnetic resonance imaging
  • heritable mutations associated with Familial Hypercholesterolaemia
  • heritable mutations which increase risk in colorectal and endometrial cancer
  • genetic testing for childhood syndromes
  • 20 new genetic testing items for the diagnosis and prognosis of certain cancers.

The Amendment Rules update private health insurance rules for:

  • procedure type classifications for hospital accommodation benefit purposes as found in Schedules 1 through 3 of the Benefits Requirements Rules 2011
  • lists of applicable MBS items for policies that cover hospital treatment, as included in the Clinical Categories of Schedule 5, and the Support Treatments List of Schedule 7, in the Complying Products Rules.

A ‘plain English’ explanation of the individual PHI amendments can be read in the Explanatory Statement accompanying the Amendment Rules.

Historically, the Department of Health has appended to the circular a further summary of the MBS amendments. As outlined in PHI Circular 20/20, to reduce the potential for inadvertent introduction of errors, please now refer to the explanation of the details which is included in the Attachment that is part of every Explanatory Statement.

The revised MBS items spreadsheet Clinical categories table with MBS items (Schedule 5 to the Complying Product Rules), and Common and Support treatments lists of MBS items (Schedule 6 and 7 to the Complying Product Rules) can be downloaded from Private Health Insurance Reform Rules.

We welcome post-implementation feedback on the private health insurance changes. Please email comments and feedback at any time to

Note: new MBS item 42504 for micro-bypass glaucoma surgery is for a service performed by a specialist with training that is recognised by the Conjoint Committee for the Recognition of Training in Micro-Bypass Glaucoma Surgery. It is anticipated a register of specialists will be accessible through Services Australia.