EXPLANATORY STATEMENT

 

Select Legislative Instrument 2007 No. 355

 

Subject - Health Insurance Act 1973

 

Health Insurance (General Medical Services Table) Regulations 2007

 

Subsection 133(1) of the Health Insurance Act 1973 (the Act) provides that the

Governor-General may make regulations, not inconsistent with the Act, prescribing all matters required or permitted by the Act to be prescribed, or necessary or convenient to be prescribed for carrying out or giving effect to the Act.

 

The Act provides, in part, for payments of Medicare benefits in respect of professional services rendered to eligible persons. Section 9 of the Act provides that Medicare benefits shall be calculated by reference to the fees for medical services set out in prescribed tables.

 

Subsection 4(1) of the Act provides that the regulations may prescribe a table of medical services (other than diagnostic imaging services and pathology services) that sets out items of medical services, the amount of fees applicable in respect of each item, and rules for interpretation of the table.

 

Subsection 4(2) of the Act provides that, unless sooner repealed, regulations made under
section 4 cease to be in force and are taken to have been repealed on the next day following the 15^th sitting day of the House of Representatives after the end of a period of 12 months beginning on the day on which the regulations are notified on the Federal Register of Legislative Instruments.

 

A table of general medical services is currently prescribed by the Health Insurance (General Medical Services Table) Regulations 2006 (the 2006 Regulations). The 2006 Regulations were notified on the Federal Register of Legislative Instruments on 19 October 2006 and commenced on 1 November 2006.

 

The purpose of the Regulations is to repeal the 2006 Regulations and to prescribe a new table of general medical services for the 12 month period commencing on 1 November 2007. The new table sets out the items of general medical services which are eligible for Medicare benefits, the amount of fees applicable in respect of each item and rules for interpretation of the table.

 

The Regulations make a number of changes to the existing table as part of the ongoing management of the table. The changes include:

o       provision of a general fee increase of 2.2 per cent for all items in the table, excluding items in Group A2 which relate to other medical practitioners (with the exception of emergency attendance after hours items), item 173 (acupuncture), Group A19 (Practice Incentive Payments other than non referral);

o       the introduction of 13 new items;

o       the amendment to the descriptors for 27 items to accurately reflect current clinical practice; and

o       additional fee increases to 15 items.

 

 

These changes have been recommended by reviews conducted by the Medical Services Advisory Committee (MSAC) and ongoing reviews by the Medicare Benefits Consultative Committee. The reviews are designed to ensure that the table reflects current medical practice and encourages best practice.

 

The MSAC has assessed the evidence supporting the safety, effectiveness and cost-effectiveness of a number of medical technologies. Consequently any new items where new technologies have been introduced or where items have been amended to include an existing technology have been assessed by MSAC.

 

Details of the Regulations are set out in the Attachment.

 

The Act specifies no conditions that need to be met before the power to make the Regulations may be exercised.

 

The Regulations are a legislative instrument for the purposes of the Legislative Instruments Act 2003.

 

The Regulations commence on 1 November 2007.

 

 

 

ATTACHMENT

 

DETAILS OF THE HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) REGULATIONS 2007

 

Regulation 1 provides for the Regulations to be referred to as the Health Insurance (General Medical Services Table) Regulations 2007.

 

Regulation 2 provides for the Regulations to commence on 1 November 2007.

 

Regulation 3 repeals the Health Insurance (General Medical Services Table) Regulations 2006.

 

Regulation 4 defines, for the purpose of the Regulations, ‘Act’ to mean the Health Insurance Act 1973 and ‘this table’ to mean the table of general medical services set out in Schedule 1.

 

Regulation 5 provides that the new table of general medical services and rules of interpretation are set out in Schedule 1.

 

In addition to re-making the table contained in the Health Insurance (General Medical Services Table) Regulations 2006, the Regulations include:

o       provision of a general fee increase of 2.2 per cent for all items in the table, excluding items in Group A2 which relate to other medical practitioners (with the exception of emergency attendance after hours items), item 173 (acupuncture), Group A19 (Practice Incentive Payments other than non referral);

o       the introduction of 13 new items;

o       the amendment to the descriptors for 27 items to accurately reflect current clinical practice; and

o       additional fee increases to 15 items.

 

PART 2 - Rules of interpretation

 

The following amendments to rules are :

 

Rule 5A

Rule 5A is amended to become rule 6. This rule provides for meaning of “patient’s medical condition requires urgent treatment” and “responsible person” for certain items.

 

Rule 5B

Rule 5B is amended to become rule 7. This rule provides for further clarification for certain items that cover after-hour periods.

 

Rule 6

Rule 6 is amended to become rule 8. This rule provides for the meaning of single course of treatment in certain circumstances.

 

Rule 7

Rule 7 is amended to become rule 9. This rule provides for the meaning of professional attendance in certain items.

 

 

Rule 8

Rule 8 is amended to become rule 10. This rule provides for further clarification of referral for certain items.

 

Rule 9

Rule 9 is amended to become rule 11. This rule provides for a method of calculating the schedule fee for certain items where the schedule fee is dependant on the number of patients seen. This rule also be amended to reflect the general fee increase of 2.2 per cent that has been applied to certain items.

 

Rule 10

Rule 10 is amended to become rule 64. This rule provides interpretation on certain circumstances to which items 10809 and 10929 do not apply.

 

Rule 11

Rule 11 is amended to become rule 12. This rule provides that certain items apply only to a service provided in the course of a personal attendance by a single medical practitioner on a single patient on a single occasion. This rule also be amended to incorporate

 

Subrule 11(5) adds items 359 and 361 to the list of items to be provided in the course of a personal attendance by a single medical practitioner on a single patient on a single occasion by way of a telepsychiatry consultation.

 

Rule 12

Rule 12 is amended to become rule 13. This rule provides interpretation for personal attendances by certain medical practitioners.

 

Subrule 12(4) be amended to include items 359 and 361 as these items are services that must be provided by medical practitioners by way of a telepsychiatry consultation.

 

Rule 12A

Rule 12A is amended to become rule 37. This rule provides interpretation of services by certain medical practitioners for items 729 to 866.

 

Rule 12AA

Rule 12AA is amended to become rule 27. This rule provides interpretation of health checks for item 717.

 

Rule 13

Rule 13 is amended to become rule 62. This rule provides interpretation that certain services may be provided by persons other than medical practitioners.

 

Rule 14

Rule 14 is amended to become rule 103. This rule provides interpretation that Group T8 services may be provided by a specialist trainee.

 

Rule 15

Rule 15 is amended to become rule 61. This rule provides interpretation for items 1 to 10943. It provides that an item in that range does not apply to a service listed in part 4 (a list of non-Medicare services).

 

 

 

Rule 15A

Rule 15A is amended to become rule 63. This rule provides interpretation for items 5000 to 5267.

 

Rule 16

Rule 16 is amended to become rule 121. This rule provides interpretation for the application of items 51700 to 53706.

 

Rule 17

Rule 17 is amended to become rule 86. This rule provides for a method of calculating the schedule fee for certain items where the schedule fee is dependant on the number of patients seen. This rule is also amended to reflect the general fee increase of 2.2 per cent that has been applied to certain items.

 

Rule 18

Rule 18 is amended to become rule 117. This rule provides for a method of calculating the schedule fee for item 44376.

 

Rule 19

Rule 19 is amended to become rule 126. This rule provides interpretation for cleft lip and cleft palate services in Groups C1, C2, C3, and C4.

 

Rule 20

Rule 20 is amended to become rule 127. This rule provides interpretation for the application of the symbol AD (dental practitioner) for Groups C2 and C3.

 

Rule 21

Rule 21 is amended to become rule 128. This rule provides interpretation for orthodontic services in certain items.

 

Rule 22

Rule 22 is amended to become rule 129. This rule provides interpretation for oral surgery services in certain items.

 

Rule 23

Rule 23 is amended to become rule 78. This rule provides interpretation for report for items 11000 to 12217. These items belong to Group D1 (miscellaneous diagnostic procedures and investigations).

 

Rule 24

Rule 24 is amended to become rule 79. This rule provides interpretation for treatment cycle of a patient.

 

Rule 25

Rule 25 is amended to become rule 80. This rule provides interpretation for items provided as part of a treatment cycle relating to assisted reproductive services not to apply.

 

Rule 26

Rule 26 is amended to become rule 81. This rule provides interpretation for items relating to assisted reproductive services not to apply in pregnancy related circumstances.

 

 

Rule 27

Rule 27 is amended to become rule 82. This rule provides interpretation for embryology laboratory services in items 13200 and 13206.

 

Rule 28

Rule 28 is amended to become rule 88. This rule provides interpretation for delivery in items 16515, 16519, and 16522.

 

Rule 29

Rule 29 s amended to become rule 118. This rule provides interpretation for maxilla in certain items.

 

Rule 30

Rule 30 is amended to become rule 119. This rule provides interpretation that items 46300 to 46534 apply only in circumstances where the service is provided in the course of an operation on a hand or hands.

Rule 31

Rule 31 is amended to become rule 120. This rule provides interpretation for the application of assistance at operations under certain items.

 

Rule 32

Rule 32 is amended to become rule 122. This rule provides for a method of calculating the schedule fee for items 51303 and 51803.

 

Rule 33

Rule 33 is amended to become rule 123. This rule provides for a method of calculating the schedule fee for item 51309.

 

Rule 34

Rule 34 is amended to become rule 90. This rule provides information on the derivation of the schedule fee for items 18219 and 18227 where the attendance goes beyond an hour.

 

Rule 35

Rule 35 is amended to become rule 105. This rule provides interpretation for the requirement of histopathological proof of malignancy in certain cases for items 30196 to 30205.

 

Rule 36

Rule 36 is amended to become rule 89. This rule provides information on the derivation of the schedule fee for items 16633 and 16636 for coverage of multiple pregnancies.

 

Rule 37

Rule 37 is amended to become rule 124. This rule provides for a method of calculating the schedule fee for items 51312.

 

Rule 38

Rule 38 is amended to become rule 106. This rule provides for a method of calculating the schedule fee for item 31340.

 

 

 

Rule 39

Rule 39 is amended to become rule 125. This rule provides interpretation for previous significant surgical complication in item 51318.

 

Rule 40

Rule 40 is amended to become rule 104. This rule provides for a method of calculating the schedule fee for item 30001.

 

Rule 41

Rule 41 is amended to become rule 16. This rule provides interpretation for consultant occupational physicians.

 

Rule 42

Rule 42 is amended to become rule 77. This rule provides interpretation for qualified sleep medicine practitioner.

 

Rule 43

Rule 43 is amended to become rule 17. This rule provides interpretation for public health physicians.

 

Rule 44

Rule 44 is amended to become rule 20. This rule provides interpretation on how items in Group A14 apply to certain patients only.

 

Rule 46

Rule 46 is amended to become rule 21. This rule provides interpretation for health assessment in certain items.

 

Rule 46A

Rule 46A is amended to become rule 22. This rule provides the meaning of child health check for item 708.

 

Rule 47

Rule 47 is amended to become rule 23. This rule provides the meaning of child health check for item 710.

 

Rule 48

Rule 48 is amended to become rule 24. This rule provides the meaning of comprehensive medical assessment for item 712.

 

Rule 48A

Rule 48A is amended to become rule 25. This rule provides the meaning of health assessment for items 714 and 716.

 

Rule 48B

Rule 48B is amended to become rule 26. This rule provides the meaning for humanitarian visa holder for items 714 and 716.

 

Rule 48C

Rule 48C is amended to become rule 28. This rule provides the meaning of health assessment for items 718 and 719.

 

Rule 49A

Rule 49A is amended to become rule 30. This rule provides interpretation for GP management plans.

 

Rule 51

Rule 51 is amended to become rule 31. This rule provides interpretation for multidisciplinary discharge care plan.

 

Rule 51A

Rule 51A is amended to become rule 32. This rule provides interpretation for team care arrangements.

 

Rule 51B

Rule 51B is amended to become rule 33. This rule provides the interpretation for associated medical practitioner for items 725 and 727.

 

Rule 52A

Rule 52A is amended to become rule 34. This rule provides for interpretation for review of plans for item 725.

 

Rule 53A

Rule 53A is amended to become rule 35. This rule provides interpretation for co-ordinate a review for item 727.

 

Rule 53B

Rule 53B is amended to become rule 36. This rule provides interpretation of contribute to a multidisciplinary care plan for items 729 and 731.

 

Rule 54

Rule 54 is amended to become rule 39. This rule provides interpretation for multidisciplinary case conference.

 

Rule 55

Rule 55 is amended to become rule 40. This rule provides interpretation for multidisciplinary discharge case conference.

 

Rule 56

Rule 56 is amended to become rule 41. This rule provides interpretation for multidisciplinary discharge case conference in a residential aged care facility.

 

Rule 57

Rule 57 is amended to become rule 42. This rule provides interpretation for multidisciplinary case conference team.

 

Rule 58

Rule 58 is amended to become rule 43. This rule provides interpretation for organise and co-ordinate and participate for a multidisciplinary case conference.

 

Rule 58A

Rule 58A is amended to become rule 44. This rule provides interpretation for co-ordinate for item 880.

 

Rule 58B

Rule 58B is amended to become rule 45. This rule provides interpretation for case conference team for item 880.

 

Rule 58C

Rule 58C is amended to become rule 46. This rule provides interpretation for the application of item 880.

 

Rule 59

Rule 59 is amended to become rule 47. This rule provides interpretation for living in a community setting for item 900.

 

Rule 60

Rule 60 is amended to become rule 48. This rule provides interpretation for residential medication management review in item 903.

 

Rule 61

Rule 61 is amended to become rule 49. This rule provides for a method of calculating the schedule fee for certain items where the schedule fee is dependant on the number of patients seen. This rule also be amended to reflect the general fee increase of 2.2 per cent that has been applied to certain items.

 

Rule 62

Rule 62 is amended to become rule 51. This rule provides interpretation for the application of subgroup 2 of Group A18 and subgroup 2 of Group A19.

 

Rule 63

Rule 63 is amended to become rule 52. This rule provides interpretation for the application of subgroup 3 of Group A18 and subgroup 3 of Group A19.

 

Rule 63A

Rule 63A is amended to become rule 53. This rule provides interpretation for the application for Group A24.

 

Rule 63AA

Rule 63AA is amended to become rule 60. This rule provides interpretation for outer metropolitan area and outer metropolitan specialist trainee for items 5906, 5908, 5910 and 5912.

 

Rule 63B

Rule 63B is amended to become rule 83. This rule provides interpretation for the application of items 14227, 14230, 14233, 14236, 14239, and 14242.

 

Rule 64

Rule 64 is amended to become rule 85. This rule provides for interpretation of approved site in items 15338 and 37220. These items provide coverage for prostate seed brachytherapy.

 

Rule 64A

Rule 64A is amended to become rule 84. This rule provides interpretation for item 14245.

 

Rule 64B

Rule 64B is amended to become rule 92. This rule provides interpretation for expressions in rule 64C (is amended to become Rule 93 – refer below) and item 16400.

 

Rule 64C

Rule 64C is amended to become rule 93. This rule provides interpretation for the application of item 16400.

 

Rule 65

Rule 65 is amended to become rule 94. This rule provides interpretation for where items in Group T10 only apply in connection with certain services.

 

Rule 66

Rule 66 is amended to become rule 95. This rule provides interpretation for the services specified in subgroups 21 to 25 in Group T10.

 

Rule 67

Rule 67 is amended to become rule 96. This rule provides interpretation for the services specified in subgroups 21, 24, 25 and 26 in Group T10.

 

Rule 68

Rule 68 is amended to become rule 97. This rule provides interpretation for the services specified in subgroups 21 in Group T10.

 

Rule 69

Rule 69 is amended to become rule 98. This rule provides interpretation for the services specified in subgroups 22 and 23 in Group T10.

 

Rule 70

Rule 70 is amended to become rule 99. This rule provides for a method of calculating the schedule fee for certain items where the schedule fee is dependant on the number of patients seen. This rule also be amended to reflect the general fee increase of 2.2 per cent that has been applied to certain items.

 

Rule 71

Rule 71 is amended to become rule 100. This rule provides interpretation for the services specified in subgroups 24 and 25 in Group T10.

 

Rule 72

Rule 72 is amended to become rule 101. This rule provides interpretation for complex paediatric case for item 25205.

 

Rule 73

Rule 73 is amended to become rule 102. This rule provides for a method of calculating the schedule fee for certain items where the schedule fee is dependant on the number of patients seen. This rule also be amended to reflect the general fee increase of 2.2 per cent that has been applied to certain items.

 

Rule 74

Rule 74 is amended to become rule 15. This rule provides for the restriction telepsychiatry consultations to rural and remote areas. This rule also be amended to include items 359 and 361.

 

Rule 75

Rule 75 is amended to become rule 18. This rule provides for the meaning of recognised emergency department and problem focussed history for Group A21.

 

Rule 76

Rule 76 is amended to become rule 19. This rule provides interpretation of prolonged attendances by emergency physicians.

 

Rule 76A

Rule 76A is amended to become rule 54. This rule provides interpretation for expressions used in rule 55 (previously rule 77A – refer below) to rule 57 (previously rule 78- refer below).

 

Rule 77A

Rule 77A is amended to become rule 55. This rule provides interpretation for GP Mental Health Care Plans.

 

Rule 77B

Rule 77B is amended to become rule 56. This rule provides interpretation for items in subgroup 1 of Group A20.

 

Rule 78

Rule 78 is amended to become rule 57. This rule provides interpretation for focussed psychological strategies.

 

Rule 78A

Rule 78A is amended to become rule 59. This rule provides for interpretation for item 4001. Item 4001 provides for a service of providing non-directive pregnancy support counselling to a woman who is concerned about a current pregnancy or a pregnancy that occurred in the 12 months.

 

Rule 79

Rule 79 is amended to become rule 108. This rule provides for interpretation of qualified surgeon for items 31539 and 31545.

 

Rule 80

Rule 80 is amended to become rule 109. This rule provides for interpretation of qualified radiologist for item 31542.

 

Rule 81

Rule 81 is amended to become rule 91. This rule provides for interpretation for the injection of botulinum toxin under items 18350 to 18373.

 

Rule 82

Rule 82 is amended to become rule 14. This rule provides interpretation of qualified medical acupuncturist for certain items.

 

Rule 82A

Rule 82A is amended to become rule 65. This rule provides interpretation for the application of item 10988.

 

Rule 82B

Rule 82B is amended to become rule 66. This rule provides interpretation for the application of item 10989.

 

 

 

Rule 83

Rule 83 is amended to become rule 67. This rule provides interpretation for the application of item 10990, 10991 and 10992.

 

Rule 84

Rule 84 is amended to become rule 68. This rule provides interpretation for the application of item 10993.

 

Rule 84A

Rule 84A is amended to become rule 69. This rule provides interpretation for the application of item 10994 and 10995.

 

Rule 85

Rule 85 is amended to become rule 70. This rule provides interpretation for the application of item 10996.

 

Rule 85A

Rule 85A is amended to become rule 71. This rule provides interpretation for the expressions used item 10997.

 

Rule 86

Rule 86 is amended to become rule 72. This rule provides interpretation for the application of item 10998 and 10999.

 

Rule 86A

Rule 86A is amended to become rule 107. This rule provides interpretation for the application of item 30688, 30690, 30692, and 30694.

 

Rule 87

Rule 87 is amended to become rule 110. This rule provides interpretation of foreign body for items 35360 to 35363.

 

Rule 87A

Rule 87A is amended to become rule 111. This rule provides interpretation for the application of item 35404, 35406 and 35408.

 

Rule 88

Rule 88 is amended to become rule 73. This rule provides interpretation for the limitation on certain items. This rule also be amended to include new item 359 in the list of items that are not applicable more than once in a 12 month period.

 

Rule 89

Rule 89 is amended to become rule 113. This rule provides interpretation for the application of items 30440, 30451, 30492 and 30495.

 

Rule 90

Rule 90 is amended to become rule 74. This rule provides interpretation for the application of items 10990, 10940 and 10941.

 

 

 

Rule 91

Rule 91 is amended to become rule 75. This rule provides interpretation for the application of items 10931, 10932 and 10933.

 

Rule 92

Rule 92 is amended to become rule 76. This rule provides interpretation for the limitations to be applied to certain items 10943, 16590, 18360, 18364 and 50303.

 

Rule 93

Rule 93 is amended to become rule 112. Tis rule provides interpretation for items 30299 and 30300.

 

Rule 94

Rule 94 is amended to become rule 87. This rule proves interpretation for the application of items 15556, 15559 and 15562.

 

Rule 95

Rule 95 is amended to become rule 115. This rule provides interpretation for the application of items 38365, 38368 and 38654.

 

Rule 96

Rule 96 is amended to become rule 116. This rule provides interpretation for the application of items 38470 to 38766.

 

Rule 97

Rule 97 is amended to become rule 50. This rule provides interpretation for the application of certain items.

 

Rule 98

Rule 98 is amended to become rule 114. This rule provides interpretation for the application for item 35412.

 

The following insertion of a new rule is :

Rule 58

The insertion of rule 58 provides for interpretation of a new Group A28. New Group A28 is Geriatric Medicine and provides for the service of Comprehensive Geriatric Assessment and Management. This is a core geriatrician activity that involves an expert assessment of the medical status and physical and psycho-social function of an older patient with multiple health and functional problems and development of a management plan which is provided to the patient’s general practitioner. There is a particular focus on addressing problems of cognition, polypharmacy, incontinence and falls which often lead to premature institutionalisation.

 

A new rule 58 provides that an item in Group A28 applies only to a service provided in the course of a personal attendance by a medical practitioner.

 

PART 3 - Services and fees

 

Professional Attendances

Consultant Physician Treatment and Management Plan

The introduction of two new items 132 and 133 provides for complex consultations, where the consultant physician will provide a comprehensive patient assessment and the creation of a consultant physician treatment and management plan of significant complexity. Item 132 provide for initial assessment of a patient with at least two morbidities and item 133 provide for a subsequent attendance for a review of a patient.

 

Geriatric medicine

The introduction of four new items 141, 143, 145, and 147 provides for the service of Comprehensive Geriatric Assessment and Management. This is a core geriatrician activity that involves an expert assessment of the medical status and physical and psycho-social function of an older patient with multiple health and functional problems and development of a management plan which is provided to the patient’s general practitioner. There is a particular focus on addressing problems of cognition, polypharmacy, incontinence and falls which often lead to premature institutionalisation.

 

Pyschiatry

The introduction of two new telepsychiatry items 359 and 361 allows for psychiatrists to provide initial tele-consultations on new patients and review referred assessment and management plans that item 291 provides for. This change will align telepsychiatry services with existing face-to-face services and encourage the use of these items by this method for patients living in rural and remote communities.

 

Items 293, 296, 297, 299, 300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319, 353, 355, 356, 357, 358, 364, 366, 367, 369, and 370 are also amended to include claiming restrictions with the new items.

 

Therapeutic Procedures

Endovascular Repair of Abdominal Aortic Aneurysms

The introduction of two new items 33116 and 33119 provides for two different techniques of endovascular repair by endoluminal grafting (by tube graft (33116) or bifurcation graft (33119)) of abdominal aortic aneurysms.

 

Photodynamic Therapy

The introduction of three new items 43021, 43022, and 43023 provide for coverage of photodynamic therapy for the treatment of choroidal neovascularisation. Item 43021 provides for photodynamic therapy service for one eye. Item 43022 provides for photodynamic therapy service for both eyes. Item 43023 provides for where photodynamic therapy has been discontinued for medical reasons.

 

Resurfacing of the Face or Neck

Items 45025 and 45026 is amended to clarify that the service listed under these items does not include fractional laser therapy.

 

Additional Schedule Fee increases

Minor schedule fee increases applies to 15 items (30058, 30259, 39327, 47735, 50115, 52120, 52132, 52138, 52319, 52379, 53004, 53054, 53058, 53068, and 53413). This maintains parity between items in Category 3 and Category 4 for the performance of oral and maxillofacial surgery.