PHI 22/19 - April Amendments for MBS Item Mapping for Clinical Categories

Page last updated: 29 March 2019

April Amendments for MBS Item Mapping for Clinical Categories (PDF 156 KB)

The Private Health Insurance (Complying Product) Amendment Rules (No.3) 2019 (the Amendment Rules) were made and registered on the Federal Register of Legislation on 29 March 2019. They commence on 1 April 2019, immediately after commencement of the Private Health Insurance (Reforms) Amendment Rules 2018. This means the new product tiers and clinical categories arrangements made in October 2018 come into effect in the first moment of 1 April 2019 and at the next moment in time (basically the same time) they are amended by these Amendment Rules made on 29 March 2019.

The Amendment Rules incorporate the professional attendance Medicare Benefits Schedule (MBS) item 115 (new to the MBS on 1 April 2019) into the common treatments list in Schedule 6 of the Private Health Insurance (Complying Product) Rules 2015 (the Complying Product Rules). Some MBS items are not allocated for the clinical categories arrangements because they are not provided in hospitals (eg, new Items 177 and 699 which are for heart health assessment through a doctor in general practice).

Twelve MBS items (20, 35, 43, 51, 92, 93, 95, 96, 183, 188, 202 and 212) are also removed from the common treatments list reflecting amendments to the MBS effective 1 March 2019. This was previously incorporated into the spreadsheet mapping MBS items for clinical categories arrangements available on the Departments website, but had not been formally changed for the Complying Product Rules.

The Amendment Rules also amend the definition of MBS item in the Complying Product Rules to include an item deemed to be in a MBS services table through determination under s3C of the Health Insurance Act 1973.

The Amendment Rules also omit itemised MBS items and instead introduce a form of descriptive words to include MBS items in the Schedule 7 support treatments list if they are hospital treatments that are:

  • in the MBS pathology services table or diagnostic imaging table; and
  • not separately listed against a clinical category or the common treatments list in the Complying Product Rules.
Support treatment MBS items which are neither diagnostic imaging nor pathology items will be retained as separately listed item numbers in a table set out in the support treatments list.

The amendment does not alter the approach to whether MBS item are included in the support treatments list. It simply ensures the support treatments list reflects changes to the MBS diagnostic imaging and pathology services tables. This will reduce the administrative burden of amendments and concomitant compilations to the Principal Rules due to the frequency of changes for diagnostic imaging and pathology MBS items. If diagnostic imaging or pathology items need to be mapped to a specific clinical category or to the common treatments list, that will still require an amendment to the Complying Product Rules.

The spreadsheet mapping MBS items for clinical categories arrangements will continue to list all MBS items relevant for the support treatments list, including the diagnostic imaging and pathology items incorporated by reference in the Complying Product Rules.

If you have any questions regarding PHI Circular 22/19 please contact the Department of Health at PHI@health.gov.au