PHI 39/19 Private health insurance rules changes – 1 July 2019

Private health insurance announcement.

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

The Private Health Insurance Legislation Amendment (No. 2) Rules 2019 (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 Amendment Rules were registered on the Federal Register of Legislation and commence on 1 July 2019. The Amendment Rules will amend the Benefit Requirements Rules to:

  • increase the minimum benefit private health insurers pay for private patient overnight and same-day accommodation fees in both private and public hospitals (the increase is in line with the annual March increase in the Cost Price Index (CPI)) of 1.3%)
  • index the monetary thresholds which provide a qualifier on the Medicare Benefits Schedule (MBS) items included in the definitions of advanced surgical patient and surgical patient by 1.6%, in line with the indexation of MBS on 1 July 2019
  • increase the minimum benefit payable for nursing home type patients’ accommodation fees for the Australian Capital Territory (ACT) and South Australia
  • reclassify MBS item 36840 from Type A (overnight procedures) to Type B (same-day procedures), and vice-versa for MBS item 36508 for the purposes of minimum benefits for hospital accommodation.

The Amendment Rules will amend the Complying Product Rules to:

  • update the daily patient contribution payable by nursing home type patients for hospital accommodation in public hospitals in the ACT
  • refine the expression of two clinical categories in Schedule 5 to include the example of 'spinal disc replacement' in the clinical category 'Back, neck and spine' and removing it from the clinical category 'Joint replacements'
  • omit 119 out-of-hospital (non-admitted) MBS items from Schedules 5, 6 and 7 of these Rules (the clinical categories, common treatments list and support treatments list respectively) as hospital insurance products cannot provide benefits for out-of-hospital services. As such, the inclusion of these items in the schedules had no legal effect and so their removal is entirely administrative in nature.

See details of the individual amendments with the Explanatory Statement accompanying the Amendment Rules.