Private Health Insurance (Prostheses) Rules 2016 (No. 4)
made under item 4 of section 333-20 of the
Private Health Insurance Act 2007
Compilation No. 2
Compilation date: 20 February 2017
Includes amendments up to: F2017L00089
Registered: 20 February 2017
This compilation is in 9 volumes
Volume 1: Parts 1–3
Volume 2: Schedule, Part A (Categories 01–05)
Volume 3: Schedule, Part A (Category 06)
Volume 4: Schedule, Part A (Categories 07–08)
Volume 5: Schedule, Part A (Categories 09–10)
Volume 6: Schedule, Part A (Categories 11–13)
Volume 7: Schedule, Part B - Human Tissue List
Volume 8: Schedule, Part C - Other Prostheses
Volume 9: Endnotes
Each volume has its own contents
About this compilation
This compilation
This is a compilation of the Private Health Insurance (Prostheses) Rules 2016 (No. 4) that shows the text of the law as amended and in force on 20 February 2017 (the compilation date).
The notes at the end of this compilation (the endnotes) include information about amending laws and the amendment history of provisions of the compiled law.
Uncommenced amendments
The effect of uncommenced amendments is not shown in the text of the compiled law. Any uncommenced amendments affecting the law are accessible on the Legislation Register (www.legislation.gov.au). The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. For more information on any uncommenced amendments, see the series page on the Legislation Register for the compiled law.
Application, saving and transitional provisions for provisions and amendments
If the operation of a provision or amendment of the compiled law is affected by an application, saving or transitional provision that is not included in this compilation, details are included in the endnotes.
Editorial changes
For more information about any editorial changes made in this compilation, see the endnotes.
Modifications
If the compiled law is modified by another law, the compiled law operates as modified but the modification does not amend the text of the law. Accordingly, this compilation does not show the text of the compiled law as modified. For more information on any modifications, see the series page on the Legislation Register for the compiled law.
Self-repealing provisions
If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.
Part 1 Preliminary
These Rules are the Private Health Insurance (Prostheses) Rules 2016 (No. 4).
These Rules are made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.
In these Rules:
accredited podiatrist means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.
Note: The registration requirements for an accredited podiatrist for the purposes of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules.
Act means the Private Health Insurance Act 2007.
cardiac home/remote monitoring system includes a component of a cardiac home/remote monitoring system.
certified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.
certified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules.
consultant physician has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.
gap permitted prosthesis means a prosthesis of a kind listed in the Schedule where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and a different amount is set out in the column under the heading 'Maximum Benefit'.
implantable cardiac event recorder includes a component of an implantable cardiac event recorder.
insulin infusion pump includes a component of an insulin infusion pump.
listed prosthesis means a kind of prosthesis listed in the Schedule to these Rules.
listing application has the same meaning as in subsection 72-10(6) of the Act.
listing criteria has the same meaning as in subsection 72-10(6) of the Act.
National Law means:
(a) for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or
(b) for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 that corresponds to the Health Practitioner Regulation National Law.
Note: The Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions that was made on 26 March 2008 provides for the enactment of the State and Territory legislation mentioned in this definition.
no gap prosthesis means a prosthesis of a kind listed in the Schedule where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and no amount is set out in the column under the heading 'Maximum Benefit'.
private hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a private hospital.
professional attendance has the same meaning as in clause 1.2.3 of the general medical services table being the table prescribed under section 4 of the Health Insurance Act 1973.
professional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.
public hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a public hospital.
Schedule means the Schedule in these Rules.
Note: Terms used in these Rules have the same meaning as in the Act―see section 13 of the Legislation Act 2003. These terms include:
complying health insurance policy
hospital-substitute treatment
hospital treatment
medicare benefit
Part 2 Benefit requirements
For item 4 of the table in subsection 72-1(2) of the Act:
(a) the Schedule lists the kinds of prostheses:
(i) in relation to which the Minister has granted an application for listing under subsection 72-10(5) of the Act; or
(ii) which are listed in accordance with section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007; and
Note: Section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the listing of a prosthesis that was a no gap prosthesis or a gap permitted prosthesis for the purposes of the National Health Act 1953 immediately before the commencement of the Act.
(aa) circumstances in which a listed prosthesis is provided for the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) are set out in rule 7; and
(ab) conditions that must be satisfied in relation to the provision of a listed prosthesis for the purposes of paragraphs (c) and (d) of item 4 of the table in subsection 72-1(2) are set out in rule 8; and
(b) rule 9 sets out the method for working out the minimum benefit and maximum benefit for hospital treatment, covered under a complying private health insurance policy, that is the provision of a listed prosthesis; and
(c) rule 10 sets out the method for working out the minimum benefit and maximum benefit for hospital-substitute treatment, covered under a complying private health insurance policy, that is the provision of a listed prosthesis.
For the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) of the Act, the following circumstances are set out:
(a) the provision of a listed prosthesis which is associated with podiatric treatment by an accredited podiatrist.
Note: Paragraph (c) of Item 4 of subsection 72-1(2) deals with the provision of a listed prosthesis in circumstances in which a medicare benefit is payable.
For the purposes of paragraphs (c) and (d) of item 4 of the table in subsection
72-1(2) of the Act, conditions that must be satisfied in relation to the provision of a listed prosthesis in the circumstances covered by paragraph (c) or (d) of that item, as the case may be, are:
(a) in relation to any kind of prosthesis where there is a statement of a requirement under the heading 'Condition' in the Schedule under the listing for that kind of prosthesis, that requirement; and
(b) in relation to a listed prosthesis that is an insulin infusion pump, also:
(i) the professional service associated with the provision of the insulin infusion pump must be a professional attendance by a consultant physician in the practice of his or her specialty; and
(ii) the professional service must be provided as a certified Type C procedure or certified overnight Type C procedure; and
(iii) the insulin infusion pump must be provided for the purpose of administering insulin.
Note: Item 4 of the table in subsection 72-1(2) of the Act states other requirements in relation to benefits for the provision of prostheses that a policy that covers hospital treatment must meet. These requirements relate to benefits for hospital treatment and, if the policy covers hospital-substitute treatment, to the benefits of that coverage as well.
(1) For a no gap prosthesis provided as part of an episode of hospital treatment in a private hospital, the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in the Schedule under the heading ‘Minimum Benefit’.
(2) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a private hospital:
(a) the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and
(b) the maximum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Maximum Benefit’.
(3) For a no gap prosthesis provided as part of an episode of hospital treatment in a public hospital:
(a) the minimum benefit is the lesser of the following amounts:
(i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or
(ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and
(b) the maximum benefit is the amount for that prosthesis listed in the column under the heading 'Minimum Benefit' in the Schedule.
(4) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a public hospital:
(a) the minimum benefit is the lesser of the following amounts:
(i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in the Schedule; or
(ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and
(b) the maximum benefit is the amount for that prosthesis listed in the column under the heading ‘Maximum Benefit’ in the Schedule.
Note: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.
(1) For a no gap prosthesis provided as part of an episode of hospital-substitute treatment the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in the Schedule under the heading ‘Minimum Benefit’.
(2) For a gap permitted prosthesis provided as part of an episode of hospital-substitute treatment:
(a) the minimum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Minimum Benefit’; and
(b) the maximum benefit is the amount for that prosthesis in the column in the Schedule under the heading ‘Maximum Benefit’.
Note 1: Private health insurers cannot cover, as part of hospital-substitute treatment, a service for which medicare benefit is payable unless the service is specified in the Private Health Insurance (Health Insurance Business) Rules ―see paragraph 121-10(3)(a) of the Act.
Note 2: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.
Part 3 Other
As a matter of normal administrative practice, applications made under subsection 72-10(2) of the Act will be considered after they have been received and, if the Minister decides to grant the application, the kind of prosthesis will be listed in the Schedule the next time the Minister makes or varies the Rules.
Note 1: Under subsection 72-10(5) of the Act the Minister must list the kind of prosthesis, set out the minimum benefit and, if the Minister considers it appropriate, the maximum benefit for the prosthesis in these Rules on the next occasion that the Minister makes or varies the Rules after he or she grants an application and the applicant has paid to the Commonwealth any initial listing fee within 14 days of being informed of the Minister's decision to grant the application.
Note 2: Under subsection 72-15(3) of the Act, the Minister may remove a kind of prosthesis from the list in the Rules if the applicant fails to pay an ongoing listing fee.
In making the decision under subsection 72-10 of the Act, the Minister may have regard to a recommendation from the Prostheses List Advisory Committee.
For a listing application to be granted to list a kind of prosthesis in Part C of the Schedule, the listing criterion is that the kind of prosthesis is an:
(i) insulin infusion pump;
(ii) implantable cardiac event recorder; or
(iii) cardiac home/remote monitoring system.
Note 1: The power to make listing criteria is in subsection 72-10(6) of the Act.
Note 2: Under subsection 72-10(7) of the Act the Minister must not grant a listing application if any applicable listing criteria are not satisfied in relation to the application.
Note 3: Under the Act the Minister may refuse to grant a listing application even if the listing criteria are satisfied. See Note to subsection 72-10(7) of the Act.