PHI 95/24 – Commencement date of Prescribed List benefit amounts

Clarification of the date when benefit amounts in the Prescribed List commence

Date published:
PHI circular type:
Prescribed List announcement
Audience:
Health sector

This PHI Circular clarifies the date when benefit amounts in the Prescribed List commence. This clarification will guide health insurers and private hospitals to manage claims for the July/August 2024 Prescribed Lists.

The Private Health Insurance (Medical Devices and Human Tissue Products) Rules (the Rules are made at least three times a year. Part 1, section 2 (1) of the Rules specifies their commencement date. This commencement date is when the Rules are ‘in force’, and the date from which health insurers must pay the benefit amounts specified in the Schedule to the Rules (i.e. the Prescribed List).

Any changes to benefit amounts that are communicated in advance are not in force until the commencement date of the updated Rules. Until that date, health insurers must pay the benefit amounts in the Rules in force at the time.

The Federal Register of Legislation holds records of legislation in force as well as legislation no longer in force. We refer stakeholders to the Federal Register of Legislation website to view the benefits payable and commencement date for current and previously in-force Rules.

Managing claims for July/August PL benefits

The Rules associated with the July 2024 Prescribed List were amended twice due to issues with transition to the Health Products Portal. The effect on health insurers’ legal obligations to pay claims for PL benefits are:

Please note:

  • Some benefits in the Amendment Rules No. 1 were subsequently changed in Amendment Rules No. 2 due to listing errors. However, there is no legal mechanism in place to support claims for repayment or refund of the difference by either health insurers or private hospitals. Health insurers are therefore obliged to reimburse claims for benefits in force at the time of the provision of the device (i.e. the subject of the claim for reimbursement).