PHI 67/19 Private Health Insurance Rules Changes 1 November 2019

Page last updated: 30 October 2019

PHI 67/19 Private Health Insurance Rules Changes 1 November 2019 (PDF 177 KB)

The Private Health Insurance Legislation Amendment Rules (No.4) 2019 (the Amendment Rules) amend the Private Health Insurance (Benefit Requirements) Rules 2011 (the Benefit Requirement Rules) and the Private Health Insurance (Complying Product) Rules 2015 (the Complying Product Rules). The Amendment Rules were registered on the Federal Register of Legislation and commence on 1 November 2019.

The Amendment Rules will amend the Benefit Requirements Rules to:

    • to omit or insert Medicare Benefit Schedule (MBS) items in Schedule 1 (minimum benefit for overnight accommodation) and Schedule 3 (minimum benefits for same-day accommodation) as a consequence of changes to the MBS effective from 1 November 2019; and
    • correct the classification of MBS item 30608 within Schedule 1 from “Type A, surgical patient” to Type A, advanced surgical patient”.
The Amendment Rules will amend the Complying Product Rules to:
    • omit or insert Medicare Benefit Schedule (MBS) items in Schedules 5,6 and 7 (clinical categories, common treatments list and support treatments list respectively) as a consequence of changes to the MBS effective from 1 November 2019;
    • move three arthroplasty MBS items from the “joint replacement” clinical category (Schedule 5) to the Common treatments list (Schedule 6);
    • remove redundant out-of-hospital MBS items from the Common treatments list (Schedule 6); and
    • in subrule 14(4) refine the expression of time in which private health insurers have to advise the Private Health Insurance Ombudsman of changes to their premiums from “14 days” to “10 business days”.

Details of the individual amendments and the Explanatory Statement accompanying the Amendment Rules can be found at https://www.legislation.gov.au/Details/F2019L01384/Download .

A summary of the amendments is at Attachment A.

Attachment A


Private Health Insurance Legislation Amendment Rules (No.4) 2019


Summary of amendments
Private Health Insurance (Benefit Requirements) Rules 2011
Amended provisionAmendments
Schedule 1 (overnight accommodation) subclause 4(3)Insert MBS item 30608 into Type A procedures, advanced surgical patient list.
Schedule 1 (overnight accommodation) subclause 6(3)Omit MBS items 30608, 3090 and 3093 from Type A procedures, surgical patient list
Schedule 3 (same-day), paragraph 4(1)(a) (table T8: Surgical Operations)Omit MBS items 32088 and 32090 from the Type B procedures band 1,T8 surgical operations list.
Schedule 3 (same-day), subclause 5(1)Omit MBS items 32089 and 32093 from the “non-band specific Type B day procedures list.

Insert MBS items 32222, 32223, 32224, 32225, 32226, 32227, 32228 and 32229 in the non-band specific Type B day procedures list.
Schedule 3 (same-day), clause 8 (Category 3 – Therapeutic procedures T8:)Omit MBS item 41846 from the Type C, category 3 Therapeutic procedures T8 list and insert MBS item 41501 in this list.
Schedule 3 (same-day), clause 8 (Category 5 – Diagnostic Imaging Service I4:)Insert MBS item 61524 in the Type C procedures, Category 5, Diagnostic Imaging Services I4 list.
Schedule 3 (same-day), clause 8 (Category 5- Diagnostic Imaging Service I5:)Insert MBS items Insert 63531, 63532, 63533, and 63534 in the Type C procedures, Category 5, Diagnostic Imaging Service I5 list.

Private Health Insurance (Complying Product) Rules 2015
Amended provisionAmendments
Subrule 14(4) – information relating to changes to premiums to be provides to the Private Health Insurance OmbudsmanOmit “14 days” from subrule 14(4) and insert “10 business days”
Schedule 5, clinical category - hospital psychiatric servicesInsert 14 new eating disorder MBS items in the hospital psychiatric services clinical category:
    90250, 90251, 90252, 90253, 90254, 90255, 90256, 90257, 90264, 90265, 90272, 90274, 90276 and 90278.
Schedule 5, clinical category Ear, nose and throatOmit MBS item 41846 from the clinical category Ear, nose and throat and insert new MBS item 41501.
Schedule 5, clinical category - Gastrointestinal endoscopyOmit MBS items 32088, 32089, 32090”and 32093.

Insert new colonoscopy MBS items :
    32222, 32223, 32224, 32225, 32226, 32227, 32228 and 32229.
Schedule 5, clinical category - Joint replacementOmit three arthroplasty MBS items 46324, 46325 and 50127 from clinical category - Joint replacement
Schedule 5, clinical category - Plastic and reconstructive surgery (medically necessary)Insert new MBS item 45627 in clinical category - Plastic and reconstructive surgery (medically necessary)
Schedule 6 – Common treatments listThe Common treatments list is repealed and a new table substituted which:
    inserts three arthroplasty MBS items 46324, 46325 and 50127 from clinical category - Joint replacement
    omits 24 out-of-hospital (non-admitted) MBS items.
    The omitted items are:
      741, 745, 761, 763, 766, 769, 772, 776, 788, 789, 792, 812, 827, 829, 867, 868, 869, 873,876, 881, 885, 891, 892 and 6087.
    Schedule 7 – Support treatments listThe Support treatments list is repealed and a new table substituted which:
      omits 31 anaesthetic MBS items and
      inserts 10 new anaesthetic MBS items.

    The omitted MBS items are;
      20705, 20805, 20953, 21927, 22001, 22018, 22040, 22045, 22050, 22070, 23021, 23022, 23023, 23031, 23032, 23033, 23041, 23042, 23043, 23051, 23052, 23053, 23061, 23062, 23071, 23072, 23073, 23081, 23082 and 23083.

    The new MBS items inserted into Schedule 7 are:
      18297, 22041, 22042, 23025, 23035, 23045, 23055, 23065, 23075 and 23085.