Private Health Insurance (Prostheses) Amendment Rules (No. 2) 2019

I, Julianne Quaine, delegate of the Minister for Health, make the following Rules.

Dated 26 February 2019

Julianne Quaine
Assistant Secretary
Office of Health Technology Assessment
Technology Assessment and Access Division

Department of Health

Contents

1  Name

2  Commencement

3  Authority

4  Schedules

Schedule 1—Amendments

Private Health Insurance (Prostheses) Rules 2019 (No.1)

1  Name

  This instrument is the Private Health Insurance (Prostheses) Amendment Rules (No. 2) 2019.

2  Commencement

  This instrument commences immediately after the commencement of the Private Health Insurance (Prostheses) Rules 2019 (No. 1).

3  Authority

  This instrument is made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.

4  Schedules

  Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.

Schedule 1—Amendments

Private Health Insurance (Prostheses) Rules 2019 (No. 1)

1  Rule 4

 Insert:

default minimum benefit has the meaning given by subrule 9(5).

Medicare Benefit item 38290 has the meaning given by subrule 9(5).

sum of default minimum benefits has the meaning given by subrule 9(5).

2  Rule 9

Repeal Rule 9, substitute:

9 Benefits for prostheses provided as part of hospital treatment

 (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 Schedule 1 under the heading ‘Minimum Benefit’.

 (1A) For a no gap cardiac ablation catheter, mapping catheter for cardiac ablation or patch for cardiac ablation provided as part of an episode of hospital treatment in a private hospital and used in a surgical procedure described in Medicare Benefit item 38290, the minimum benefit and the maximum benefit for the prosthesis are as follows:

 (a) if the sum of the default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the minimum benefit and the maximum benefit are each the default minimum benefit for the prosthesis;

 (b) if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the minimum benefit and the maximum benefit are each to be calculated using the following method: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.

Note: For example, if a cardiac ablation catheter, a mapping catheter for cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the minimum benefit and maximum benefit for the cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399.

 (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 Schedule 1 under the heading ‘Minimum Benefit’; and

 (b) the maximum benefit is the amount for that prosthesis in the column in Schedule 1 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 Schedule 1; 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 Schedule 1.

 (3A) For a no gap cardiac ablation catheter, mapping catheter for cardiac ablation or patch for cardiac ablation, provided as part of an episode of hospital treatment in a public hospital and used in a surgical procedure described in Medicare Benefit item 38290:

 (a) the minimum benefit for the prosthesis is the lesser of:

 (i) the amount for that prosthesis calculated in accordance with subrule (3B); 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 the prosthesis calculated in accordance with subrule (3B).

 (3B) The amount for a prosthesis calculated in accordance with this subrule is the following amount:

 (a) if the sum of default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the amount is the default minimum benefit for the prosthesis;

 (b) if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the amount is to be calculated as follows: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.

Note: For example, if a cardiac ablation catheter, a mapping catheter for cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the amount calculated in accordance with subrule (3B) for the cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399. 

 (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 Schedule 1; 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 Schedule 1.

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.

 (5) For the purposes of this Rule:

the default minimum benefit for a prosthesis is the amount for that prosthesis listed in the Column in Schedule 1 under the heading ‘Minimum Benefit’;

Medicare Benefit item 38290 means item 38290 in Group T8 of the Health Insurance (General Medical Services Table) Regulations 2018.

the sum of default minimum benefits for a procedure is the sum of the default minimum benefits for each cardiac ablation catheter, mapping catheter for cardiac ablation and patch for cardiac ablation used in that procedure;

3  Schedule 1, Part A (cell at table item with Billing Code MN237, column headed “Minimum Benefit”)

Repeal “$342.00”, substitute “$43.00”.

4  Schedule 1, Part A (cell at table item with Billing Code DE678, column headed “Condition”)

Insert “Limited to use in patients with spinal tumours only.”

5  Schedule 1, Part A (cell at table item with Billing Code DE679, column headed “Condition”)

Insert “To be provided only to patients with Spinal Tumours”

6  Schedule 1, Part A (cell at table item with Billing code DE680, column headed “Condition”

Insert “To be provided only to patients with Spinal Tumours”

7  Schedule 1, at the end of Part C

Insert:

08.18 - Cardiac Ablation

08.18.01 - Radio frequency (RF) Ablation

08.18.01.01 - Ablation Catheter

Abbott

ABBOTT MEDICAL AUSTRALIA PTY LTD.

Biotronik

Biotronik Australia Pty Ltd

Boston Scientific

Boston Scientific Australia Pty Ltd

Johnson and Johnson

Johnson & Johnson Medical Pty Ltd

Medtronic, single unit

Medtronic Australasia Pty Ltd

08.18.01.02 - Patch

Abbott

ABBOTT MEDICAL AUSTRALIA PTY LTD.

Boston Scientific

Boston Scientific Australia Pty Ltd

Johnson and Johnson

Johnson & Johnson Medical Pty Ltd

08.18.01.03 - Mapping Catheter

Abbott

ABBOTT MEDICAL AUSTRALIA PTY LTD.

Johnson and Johnson

Johnson & Johnson Medical Pty Ltd

08.18.02 - Cryoablation

08.18.02.01 - Ablation Catheter

Medtronic Australasia Pty Ltd

08.18.02.02 - Mapping Catheter

Medtronic Australasia Pty Ltd