Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) REGULATIONS 2000 2000 NO. 292

EXPLANATORY STATEMENT

STATUTORY RULES 2000 No. 292

Issued by authority of the Minister for Health and Aged Care

Health Insurance Act 1973

Health Insurance (General Medical Services Table) Regulations 2000

The Health Insurance Act 1973 ("the Act") provides for payments by way of medicare benefits and payments for hospital services.

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

Section 4 of the Act provides that the regulations may prescribe a table of medical services, (other than diagnostic imaging services and pathology services) ("the table"). The Health Insurance (19992000 General Medical Services Table) Regulations 1999 currently prescribe such a table. Section 4 of the Act also provides that, if not sooner repealed, Regulations made under Section 4 cease to have effect on the day after the 15th sitting day of the House of Representatives after a period of 12 months beginning on the day on which the Regulations are gazetted.

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.

The Regulations amended the current table of general medical services to, among other things, include fee increases from 1 November 2000 as announced in the 2000 Federal Budget, as follows:

-       a 2. 1% increase for general practitioner attendances (items 1 to 51, 193, 195, 601 and 602) and related items (items 160 to 164, 410 to 417, and 700 to 779), being full indexation as guaranteed by the General Practice Memorandum of Understanding (MOU) (refer column 3 of Part 3 - Services and fees); and

-       a 1.2% increase for all other items in the table, except for other non-referred attendances (items 52 to 98, 697 and 698), family group therapy (items 170 to 172), and attendance for acupuncture (item 173), in line with the decision taken in the Budget to reduce the indexation level by 0.9% to take into account windfall gains associated with the introduction of the Goods and Services Tax and removal of the Wholesale Sales Tax (refer column 3 of Part 3 - Services and fees).

The Regulations also incorporated changes to items in the table which resulted from ongoing reviews by the Medicare Benefits Consultative Committee. These reviews are designed to ensure that the table reflects current medical practice and encourages best practice.

The changes to items included the insertion of new services and the deletion of obsolete services, for example, insertion of new item 31470 for laparoscopic splenectomy and deletion of item 30470 covering repair of bile duct fistula, following a review of upper gastrointestinal surgery. A number of items were also amended, for example, item 35638 (complex operative laparoscopy) and items 35623 and 35636 (resection of myoma/uterine septum), following a review of obstetrics and gynaecology. Other items were amended for clarification, for example items 42698, 42701 and 42702 covering lens extraction and insertion of artificial lens.

The Regulations also provided for the repeal of the 1999-2000 General Medical Services Table.

Details of the Regulations are set out in the Attachment.

The Regulations commenced on 1 November 2000.

ATTACHMENT

Details of the Health Insurance (General Medical Services Table) Regulations 2000

Regulation 1 provides for the Regulations to be referred to as the Health Insurance (General Medical Services Table) Regulations 2000.

Regulation 2 provides for the Regulations to commence on 1 November 2000.

Regulation 3 provides for the repeal of the Health Insurance (1999-2000 General Medical Services Table) Regulations 1999.

Regulation 4 provides definitions for the purposes of the Regulations.

Regulation 5 prescribes the new Table of General Medical Services and Rules of Interpretation as set out in Schedule 1.

The General Medical Services Table is redrafted each year commencing on the first of November. The redraft takes the form of duplicating all rules and services that have not been changed or amended from the previous Regulation. Listed below are the relevant changes and amendments that have been agreed to by the Minister of Health and Aged Care relating to the 2000-2001 Budget decisions and reviews undertaken by the Department with the medical profession.

Schedule 1 - Table of General Medical Services

Part 1 - Prescription of table

Rule 1 provides an explanation of how the table operates. The insertion of this Rule resulted in consequential renumbering of the rules of interpretation in Part 2.

Part 2 - Rules of Interpretation

Rule 2, part (1) - amends the definition of "institution" by replacing "nursing home" with "residential aged care facility", to maintain consistency with the terminology contained in the Aged Care legislation.

Subrule 5 (2) qualifies the meaning of 'professional attendance' in subrule 5 (1) to exclude the supply of vaccine to a patient in respect of items 3 to 96 inclusive, where the cost of the vaccine is not subsidised by the Commonwealth or a State. This means that vaccine supplied under the Pharmaceutical Benefits Scheme or under a Commonwealth or State funding agreement, for example, would be included in a 'professional attendance' in respect of items 3 to 96 inclusive.

The purpose of subrule 5 (2) is to provide that the cost of supplying a vaccine which is not subsidised by the Commonwealth or a State is separate from a 'professional attendance' in respect of items 3 to 96 inclusive, such that medical practitioners who bulk bill are not precluded from passing on the cost of supplying that vaccine to their patients. This is the effect of the subrule when read together with section 20A of the Health Insurance Act 1973 and associated provisions dealing with bulk billing.

Subrules 8 (1), (2), (3), (4), (9), (10), (11), (12) and (13) amend fee levels to reflect the general fee increase.

Rule 14 is amended by deleting item 53460 and replacing it with item 53706 to reflect the introduction of new items in this area.

Subrules 16 (1), (2), (3), (4), (5) and (6) and 17 (1) and (2), amend fee levels to reflect the general fee increase (less 0.9%).

Rule 29 is amended by deleting item 45719 and replacing it with item 45720 to take account of renumbering of the items.

Subrule 35 (b) and rules 42, 43 and 47, amend fee levels to reflect the general fee increase (less 0.9%) to apply to certain anaesthetic services.

Rules 51, 52, 53, 54, 57, 58, 62 and 63 are amended and a proposed new Rule 61 is added to reflect amendments and additional items to the enhanced primary care items covering health assessments, care planning and case conferences. New items have been introduced for provision of services to care recipients in residential aged care facilities. These Rules have also been amended to replace "nursing home" with "residential aged care facility" to reflect changes in Aged Care legislation.

The specific amendments are as follows:

Rule 51 (1)(b), 52 (1)(b) and 52 (2)(c) amended to replace "resident of a nursing home" with "care recipient in a residential aged care facility" to reflect changes in Aged Care legislation whereby "nursing homes" are replaced by "residential aged care facilities".

Rule 52 amended by adding a new part:

"(3) Items 730, 734, 736, 738, 775, 778 and 779 apply only to a service in relation to a patient who:

(a) suffers from at least one medical condition:

(i) that has been (or is likely to be) present for at least 6 months; or

(ii) that is terminal; and

(b) is a care recipient in a residential aged care facility; and

(c) is not an in-patient of a hospital or day-hospital facility."

Rule 53 (4)(b) amended by replacing the word "giving" with "offering".

Rule 54 (1) amended by adding item 730 - "For items 720, 722, 724, 726, 728 and 730....".

Rule 54 (2)(e) amended by replacing the word "giving" with "offering".

Rule 57 (2)(c) amended to read - "offering a copy of relevant parts of the revised multidisciplinary care plan (if any) to the patient, and giving copies to persons who, under the revised plan, will give the patient the treatment, service and care mentioned in the plan;"

Rule 58 (1) amended to read as follows: "For items 726, 728 and 730, a contribution to a multidisciplinary care plan, a multidisciplinary discharge care plan or a multidisciplinary care plan in a residential aged care facility must be at the request of the person or residential aged care facility who prepares the plan, and may include:...."

Rule 58 (2) amended to read as follows: "Contribution to a plan does not necessarily include preparation of the plan or part of the plan."

New Rule 61 added - Meaning of a multidisciplinary case conference in a residential aged care facility

"For items 734, 736, 738, 775, 778 and 779, a multidisciplinary case conference in a residential aged care facility is a multidisciplinary case conference carried out in relation to a care recipient in a residential aged care facility."

Rule 62, first line, amended to read: "For the items mentioned in rules 59, 60 and 61, a multidisciplinary case conference. team:..."

Rule 63 amended by adding new items 734, 736 and 738 to first line.

Rule 63 (1)(f) amended to read as follows: "offering the patient, and giving each other member of the team a summary of the conference."

Rule 63 (2) amended to include new items 775, 778 and 779.

In addition to the above amendments, minor drafting changes have been incorporated for correction or clarification.

Part 3 - Services and Fees

There have been 10 major reviews of the services in the table by the Department. These reviews related to services provided under the enhanced primary care items, case conferences for consultant physicians, nursing home attendances, assisted reproductive services, breast biopsy using vacuum-assisted breast biopsy device, upper gastro-intestinal surgery, obstetrics and gynaecology, lens extraction and insertion, oral and maxillo-facial services and total ear reconstruction.

Enhanced Primary Care

New items have been included for provision of services to care recipients in residential aged care facilities. New item 730 enables a medical practitioner to contribute to a care plan in a residential aged care facility. Items 734, 736, 738, 775, 778 and 779 enable a medical practitioner to organise and participate in a case conference for a care recipient in a residential aged care facility.

Case Conferences for Consultant Physicians

A range of new items have been included for case conferences for consultant physicians in community settings and for discharge planning for hospital in-patients. These items provide for case conferencing in residential aged care facilities.

Four new items (801, 803, 805 and 807) cover the organisation of, or participation in, a community case conference with a multidisciplinary team of at least three other formal care providers. A further four items (809, 811, 813 and 815) cover the organisation of, or participation in, a discharge case conference.

Similar to the enhanced primary care items, these items have been developed in recognition that improved coordination in community settings leads to improved patient outcomes through a more flexible, efficient and responsive match between patients' needs and services.

Nursing Home Attendances

With the introduction of the Aged Care Act 1997, the use of the term "nursing home" throughout the table was no longer appropriate. The table has been reviewed and references in items to "nursing home" replaced with "residential aged care facility".

Assisted Reproductive Services

The amendment to item 13200 covering assisted reproductive technology (ART) services removes the 6-cycle limit on claims for benefits for stimulated ART cycles under this item.

Breast Biopsy using vacuum-assisted breast biopsy device

.New item 30358 covers breast biopsy using a vacuum-assisted breast biopsy device ("Mammotome"). This follows a recommendation of the Medicare Services Advisory Committee for public funding of this new technology.

Upper Gastro-intestinal (GI) Surgery

A number of changes to general surgery items in the table have been made following a review of upper GI services, to reflect changes in clinical practice in this area (particularly laparoscopic procedures) and to encourage best practice:

-       new items and amendments to existing items covering procedures associated with enteral feeding (31456 to 31462), management of gastro-oesophageal reflux and paraoesophageal hernias (30532, 30533, 31464 to 31468), biliary surgery (30472, 31472), and dilatation of upper GI stricture (41819, 41820).

-       new items for laparoscopic splenectomy (31470), and drainage of pus, blood or bile (31454).

-       amendment to items 30536 to 30539 (oesophagectomy), items 30461 to 30464 (resection of bile duct carcinoma), and item 30596 (splenorrhaphy or partial splenectomy).

Obstetrics and Gynaecology

A number of changes have been made to obstetrics and gynaecology items in the table to reflect current practice:

-       new items covering external cephalic version (16501), laparoscopic resection of complicated (level 415) endometriosis (35641), resection of uterine septum (35634, 35635), and control of post-operative haemorrhage following gynaecological surgery (35759).

-       amendments to items 35638 (complex operative laparoscopy), and 35623 and 35636 (resection of myorna/uterine septum).

Lens Extraction and Insertion

Items 42698, 42701 and 42702 have been amended to clarify that benefits are not payable for lens extraction and insertion performed for correction of refractive error only.

Oral and Maxillo-facial Services

Various changes have been introduced following a major review of oral and maxillofacial services by approved dental practitioners to better reflect modern practice and advances in the craft.

Eighty-nine new items have been introduced in recognition of modern practice and/or to complement existing services (51900 to 52006, 52010, 52025, 52031, 52035, 52056, 52058, 52059, 52061, 52062, 52064, 52073, 52094, 52095, 52097, 52098, 52130, 52131, 52133, 52136, 52137, 52150 to 52186, 52320, 52424 to 52484, 52826 to 52832, 53004, 53007, 53017, 53050 to 53066, 53070, 53200, 53220, 53226, 53236 to 53242, and 53600 to 53706).

Sixteen existing items have been amended to address fee anomalies, introduce an explicit oral and maxillo-facial region restrictor, and/or as a consequence of the introduction of the new items (52027, 52034, 52055, 52057, 52060, 52063, 52090, 52345, 52351, 52357, 52363, 52369, 52375, 52382, 53003, 53068 and 53223).

Total Ear Reconstruction

New items 45660 and 45661 have been included to cover total complex reconstruction of the external ear for congenital absence, microtia or post-traumatic loss of pinna. This follows a recommendation of the Medicare Services Advisory Committee for public funding of this new procedure.


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