Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (1996-97 DIAGNOSTIC IMAGING SERVICES TABLE) REGULATIONS(AMENDMENT) 1997 NO. 12

EXPLANATORY STATEMENT

STATUTORY RULES 1997 No. 12

Issued by the authority of the Minister for Health and Family Services

Health Insurance Act 1973

Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations (Amendment)

The Health Insurance Act 1973 ('the Act') provides, in part, for the payment of Medicare benefits for professional services rendered by medical practitioners.

Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.

Section 4AA of the Act provides that regulations may prescribe a table of diagnostic imaging services ("the table") and the Health Insurance (1996-97 Diagnostic Imaging Services Table) Regulations prescribe such a table.

Section 9 of the Act provides that Medicare benefits shall be calculated by reference to the fees for medical services set out in the table ("Schedule fees"). Section 10 of the Act provides that a Medicare benefit is payable at the rate of 75% of the Schedule fee for a service that is rendered in a hospital or a day hospital facility, or at the rate of 85% of the fee in other cases, that is, nonhospital services. Services may be patient billed, or the Medicare benefit may be assigned by the patient to the practitioner under section 20A of the Act, The latter is sometimes referred to as "bulk billing" or "direct billing". If this applies, the practitioner must accept the Medicare benefit in full settlement for the services rendered.

Section 10 also provides that where the rate of 85% applies for a service and the Schedule fee exceeds the amount of benefit by more than the greatest permissible gap, the benefit is taken to be the Schedule fee less the greatest permissible gap.

The greatest permissible gap was changed from $26.80 to $50.00 from 17 December 1996 following the commencement of Item 3 in Schedule 2 of the Health Insurance Amendment Act (No. 2) 1996. This change was part of the 1996 Budget initiatives. Section 10A provides for the greatest permissible gap to be indexed and the figure of 526.80 had been indexed to 530.20 from 1 November 1996,

The effect of the amendment to the greatest permissible gap is to decrease the Medicare benefits Payable for both assigned and patient billed non-hospital services where the Schedule fee for those services exceeds 5201.33.

The purpose of the Regulations is to increase Schedule fees, for items where the Schedule fee exceeds 5201.33, by an amount calculated to provide increased Medicare benefits approximately equal to the decrease in Medicare benefits for assigned non-hospital services. The increased Schedule fee for each item in the Regulations was calculated having regard to the utilisation of services, fees and benefits billed under both assigned and patient billed services, rendered as hospital or non-hospital services from an analysis of statistical data for 1995/96.

The Regulations provide for increases to the fee for items in the diagnostic imaging services table where the fee exceeds $201.33.

The practical outcome of the Regulations is to offset the decrease in Medicare payments for bulk billed non-hospital services.

The Regulations also amend two fluoroscopy items in the table to provide that benefits are payable only where the services are not rendered in association with another radiographic examination.

The Regulations come into effect from 19 February 1997.


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