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The Federal Register of Legislation holds records of legislation in force as well as legislation no longer in force.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:
- The benefit amounts payable between 1 July 2024 and 7 August 2024 are those specified in the Schedule to the Private Health Insurance (Medical Devices and Human Tissue Products) Rules (No. 1) 2024.
- The benefit amounts payable between 8 August 2024 and 31 October 2024 are those specified in the Schedule to the Private Health Insurance (Medical Devices and Human Tissue Products) Amendment (No. 2) Rules 2024 (the Amendment Rules No. 2).
- The benefit amounts in the Private Health Insurance (Medical Devices and Human Tissue Products) Amendment (No. 1) Rules 2024 (the Amendment Rules No. 1) were never in force. While the Amendment Rules No. 1 were registered on 30 July 2024, with a commencement date of 8 August 2024, they were replaced by the Amendment Rules No. 2 before the commencement date of the Amendment Rules No. 1. Therefore the benefits in effect from 8 August 2024 where those included in the Schedule to the Amendment Rules No. 2.
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).