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HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) REGULATIONS 2008 (SLI NO 211 OF 2008)
Select Legislative Instrument 2008 No. 211
Health Insurance Act 1973
Health Insurance (General Medical Services Table) Regulations 2008
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.
Part II of the Act provides for the payment of Medicare benefits for 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. The Health Insurance (General Medical Services Table) Regulations 2007 (the 2007 Regulations) currently prescribe such a table.
Subsection 4(2) of the Act provides that unless repealed earlier, these Regulations will cease to be in force and will be taken to have been repealed on the day following the 15th sitting day of the House of Representatives after the end of a 12 month period beginning on the day when the regulations were registered on the Federal Register of Legislative Instruments. The 2007 Regulations were registered on the Federal Register of Legislative Instruments on 19 October 2007 and commenced on 1 November 2007.
The purpose of the Regulations is to repeal the 2007 Regulations and prescribe a new table of general medical services for the 12 month period commencing on 1 November 2008. The new table reproduce the table contained in the 2007 Regulations with some amendments to the rules of interpretation and to the schedule of services and fees.
The changes include:
- a fee increase of 2.3% for all items in the table, excluding items in Group A2 which relate to medical practitioners other than general practitioners (excepting emergency attendance after hours items), item 173 (acupuncture), Group A19 (Practice Incentive Payments other than non-referral). These items are not increased for the following reasons:
- Group A2 (attendance) items and item 173 (acupuncture) are reserved for services provided by medical practitioners who are not vocationally registered, i.e. have not undertaken continuing medical education programs offered by the Royal Australian College of General Practitioners. Services provided by vocationally registered practitioners attract higher benefits.
- Group A19 items are claimed in association with payments under the Practice Incentive Payments program which aims to reward provision of comprehensive quality patient care.
- the introduction of 29 new items; and
- amendments to the descriptors for 42 items to accurately reflect current clinical practice.
These changes have been recommended in reviews by the Medicare Benefits Consultative Committee. The reviews are designed to ensure that the table reflects current medical practice and encourages best medical practice.
Details of the Regulations are set out in the Attachment.
Amendments to the Regulations are discussed and formulated in co-operation with Medicare Australia, the Australian Medical Association and relevant professional medical groups including the Australian Association of Consultant Physicians, the Australian and New Zealand Association of Oral and Maxillofacial Surgeons, the Australian Society of Anaesthetists and the National Association for Medical Deputising.
The Act specifies no conditions which 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 2008.
ATTACHMENT
DETAILS OF THE
HEALTH INSURANCE (GENERAL MEDICAL SERVICES TABLE) REGULATIONS 2008
Regulation 2 – Commencement
This regulation provides for the Regulations to commence on 1 November 2008.
Regulation 3 – Repeal
This regulation repeals the Health Insurance (General Medical Services Table) Regulations 2007 (as amended).
Regulation 4 – Definitions
This regulation provides that for the purpose of the Regulations, Act means the Health Insurance Act 1973 and this table means the table of general medical services set out in
Schedule 1.
Regulation 5 – General medical services table
This regulation provides that the new table of general medical services (other than diagnostic imaging services and pathology services) set out in Schedule 1 is prescribed for subsection 4(1) of the Act.
The following amendments to rules are:
Rules 3, 6, 9, 20, 27, 99 and 102 are amended to include references to new items in Part 3 of this table or to clarify existing policy as does new rule 5A.
Rule 3
Subrule (1) is amended to define transitional hours as either the time between 6pm and 8pm on a weekday (not being a public holiday) or between 12pm and 1pm on a Saturday. This definition accompanies new items 603 and 696 which provides increased benefits for urgent medical services rendered during these times.
Subrule (2A) is inserted to define therapeutic substance as a therapeutic substance administered as part of a medical service, for the clinical indication for which it has been registered by the Therapeutic Goods Administration. The amendment prevents benefits being paid for the administration of a therapeutic substance for a non-TGA approved purpose.
Rule 5A
New rule 5A applies to a general practitioner who has been the subject of an adverse determination under section 106TA and subparagraph 106U(1)(g)(i) of the Act. The rule authorises the services provided by the general practitioner to attract a lower level of benefit.
Rule 6
Rule 6 governs items for urgent medical treatment. Subrules (1) and (3) are amended to include reference to new items 603 and 696 which provide for increased benefits for urgent medical services rendered during transitional hours.
Rule 9
Rule 9 defines professional attendance in relation to specified items. Subrule (1) is amended to reference new items 603 and 696 which provide for increased benefits for urgent medical services rendered during transitional hours.
Rule 20
Paragraphs (2A)(c) and (5)(b) is amended to omit reference to approved day-hospital facility. These amendments effect the current definition of hospital in section 3 of the Act.
Rule 27
Subrule (4) governs item 717 (health checks of 45–49 year olds). The amendment replaces the term patient’s usual doctor and accompanying definition with the term patient’s usual medical practitioner which is defined in rule 3.
Rule 99
Rule 99 defines amount in items 25025, 25030 and 25050. Paragraphs (1)(d), (2)(d) and (3)(d) be amended to reference new item 22051 which pays benefits for intra-operative transoesophogeal echocardiography (ITOE) used as part of the anaesthetic monitoring of a patient during cardiac surgery (anaesthetic monitoring using ITOE).
Rule 102
Rule 102 is amended to permit eligible medical practitioners to claim benefits for services associated with assistance at anaesthesia.
Part 3 – Services and fees
Attendances
All items in Group A2 of the table is amended so that they may also apply to services rendered by a general practitioner to whom new rule 5B applies.
Items 135 and 289 provide benefits for services rendered to a patient with autism or other pervasive developmental disorder. These items are amended to clarify that eligible patients are not limited to those with autism but include patients with other pervasive developmental disorders.
New items 603 and 696 extend the after-hours period for urgent out-of-surgery attendances by general practitioners and other medical practitioners, respectively, to include the period from 6pm to 8pm on a weekday (not being a public holiday) and from 12pm to 1pm on a Saturday.
Item 711 provides benefit for a Healthy Kids Check undertaken by a practice nurse on behalf of, and under the supervision of a medical practitioner (including a general practitioner). The item is amended to permit the Check to also be undertaken by a registered Aboriginal health worker.
Items 731(b), 50303, 50516, 50524, 50532, 50552, 50560, 50568, 50572, 50600 are amended to delete reference to approved day-hospital facility. These amendments are consequential upon amendments to paragraphs 20(2A)(c) and 20(5)(b) which reflect the revised definition of hospital in the Act.
Diagnostic procedures and investigations
Item 11600 provides benefit for blood pressure monitoring. The amendment specifies the category of anaesthesia employed.
Therapeutic Procedures
New item 13015 permits payment of benefit for hyperbaric oxygen therapy to treat soft tissue radionecrosis or chronic or recurring wounds where hypoxia can be demonstrated.
New item 13251 permits payment of benefit for intracytoplasmic sperm injection for assisted reproductive technologies which address male factor infertility.
New item 20804 permits payment of benefit for initiation of management of anaesthesia for microvascular free tissue flap surgery involving the anterior or posterior lower abdomen.
Items 13876, 22012 and 22014 provide benefits for blood pressure monitoring. The amendments clarify the frequency with which the procedures may be performed if benefits are to be paid.
New item 22051 permits payment of benefits for ITOE used as part of the anaesthetic monitoring of a patient during cardiac surgery. This item more appropriately denote the service as a component of anaesthesia and differentiate it from ITOE used for diagnostic purposes.
Item 30001 provides benefit for abandoned surgery. The amendment clarify existing policy, viz., that this item may not be claimed in association with any other items or procedures listed in Group T8 (Surgical Operations) of the Medicare Benefits Schedule.
New items 37605 and 37606 permits payment of benefits for transcutaneous sperm retrieval and for open surgical sperm retrieval, respectively, for intracytoplasmic sperm injection.
New item 36658 permits payment of benefits for the removal of a pulse generator and leads used for sacral nerve stimulation.
New items 36660 and 36662 permit payment of benefit for the removal and replacement of a pulse generator and leads, respectively, used for sacral nerve stimulation.
The following 17 new items permit payment of benefit for the following services:
- Item 45882 - treatment of a premalignant lesion of the oral mucosa using cryotherapy, diathermy or carbon dioxide laser.
- Item 45885 - ligation of a facial, mandibular or lingual artery or vein, or artery and vein.
- Item 45888 - removal of a deep foreign body using interventional imaging techniques.
- Item 45891 - repair to 1 defect using temporalis muscle by a single stage local flap.
- Item 45894 - free grafting of a granulating area (mucosa or split skin).
- Item 45897 - grafting of, including plastic closure of associated oro-nasal fistulae and ridge augmentation, of a unilateral alveolar cleft (congenital).
- Item 45900 - fixation of the mandible by intermaxillary wiring, excluding wiring for obesity.
- Item 45939 - cryosurgery of the peripheral branches of the trigeminal nerve for pain relief.
- Item 45945 - treatment of a dislocation of the mandible requiring open reduction.
- Item 45975 - treatment of a fracture of the unilateral or bilateral maxilla, not requiring splinting.
- Item 45978 - treatment of a fracture of the mandible, not requiring splinting.
- Item 45981 - treatment of the zygomatic bone, not requiring surgical reduction.
- Item 45984 - treatment of a complicated fracture of the maxilla involving viscera, blood vessels or nerves, requiring open reduction not involving the use of a plate.
- Item 45987 - treatment of a complicated fracture of the mandible involving viscera, blood vessels or nerves, requiring open reduction not involving the use of plate.
- Item 45990 - treatment of a complicated fracture of the maxilla involving viscera, blood vessels or nerves requiring open reduction involving the use of a plate.
- Item 45993 - treatment of a complicated fracture of the mandible involving viscera, blood vessels or nerves requiring open reduction involving the use of a plate.
- Item 45996 - treatment of a closed fracture of the mandible involving a joint surface.
- Item 52131 provides benefit for bone grafting with internal fixation. The item is amended so that it may be claimed in association with item 52300 (single stage local flap).
Cleft lip and cleft palate services
Item 75621 provides benefit for the provision and fitting of a surgical template. The item is amended so that it may be claimed in association with the relevant Category 3 (Therapeutic procedures) item.