EXPLANATORY STATEMENT

 

Select Legislative Instrument 2005 No. 100

 

Issued by the Authority of the Minister for Health and Ageing

 

Health Insurance Act 1973

 

Health Insurance (Pathology Services) Amendment Regulations 2005 (No. 1)

 

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.

 

Subsection 16A(3) of the Act provides that a Medicare benefit is not payable in respect of a pathology service that has been rendered by or on behalf of an approved pathology practitioner unless the service was rendered pursuant to a request made to the approved pathology practitioner by the treating practitioner or another approved practitioner to whom the treating practitioner has made a request for service.  The Health Insurance (Pathology Services) Regulations (the Principal Regulations) currently prescribe the particulars which must be included in requests for pathology services.

 

The name of a patient’s private health insurance fund and the membership number, or other unique identifier allocated to the person by the fund, are not among the particulars which must be included in requests for pathology services.  Under the current regulatory provisions both pathology laboratories and patients incur costs and inconvenience as the laboratories endeavour to establish a patient’s private health insurance status.

 

The difficulty for the patient arises when they elect to be a private patient and use their private health insurance.  Under the current arrangements a bill may be sent to the patient rather than directly to the appropriate health fund, thereby requiring the patient, who may be seriously ill, to make the claim on the fund for the payment of the service.  This may then delay payment to the pathology service provider.

 

The purpose of the Regulations is to enable hospitals to record the name of a patient’s private health insurance fund and the membership number, or other unique identifier allocated to the person by the fund, on a request for pathology services.  These details would only be recorded with the consent of the patient, and would only apply where a person is a private patient in a recognised hospital, a private patient in a private hospital, or a private patient in a day hospital facility.  The Regulations are a low cost, practical means of enabling hospitals, subject to a patient’s consent, to provide pathology providers with the details of a patient’s private health insurance, thereby simplifying the payment of benefits.

 

The inclusion of a patient's private health insurance status on a request for pathology services allows the patient to access the benefits of the Health Insurance Commission’s (HIC) “Electronic Claim Lodgement and Information Processing System” (ECLIPSE).  ECLIPSE has the capacity to simplify billing arrangements for in-hospital admitted services by sending the bill directly to the appropriate health fund. 

 

The Regulations provide that failure of the person to consent to the inclusion of their private health insurance details in the request for a pathology service does not affect any entitlement the person may have to a Medicare benefit, or a benefit payable by a private health insurance fund, in respect of the service.

 

The Regulations also update the citation of the Principal Regulations in line with current drafting practice.

 

The Australian Association of Pathology Practices, the Royal College of Pathologists of Australia, the National Coalition of Public Pathology, the Australian Private Hospitals Association and the HIC have been consulted and support the amendment as a means of improving the efficiency of delivering pathology services to privately insured in-hospital patients.

 

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 the day after they are registered on the Federal Register of Legislative Instruments.

 

ATTACHMENT

 

DETAILS OF THE Health Insurance (Pathology Services) Amendment Regulations 2005 (No. 1)

 

Regulation 1 provides for the Regulations to be referred to as the Health Insurance (Pathology Services) Amendment Regulations 2005 (No. 1).

 

Regulation 2 provides for the Regulations to commence on the day after they are registered on the Federal Register of Legislative Instruments.

 

Regulation 3 provides for Schedule 1 to amend the Health Insurance (Pathology Services) Regulations (the Principal Regulations). 

 

Schedule 1 - Amendment

 

Item [1]

Item 1 amends regulation 1 of the Principal Regulations, to provide for the Principal Regulations to be referred to as the Health Insurance (Pathology Services) Regulations 1989.

 

Item [2]

Item 2 inserts a note after subregulation 4(2).  The note indicates that a request in respect of a person who is a private hospital patient may also contain information about the person’s private health insurance, and refers the reader to subregulation 4(5A) (see item [3], below).

 

Item [3]

Item 3 inserts new subregulations 4(5A) and 4(5B). 

 

Subregulation 4(5A) provides that a request for a pathology service in respect of a person described in subparagraph 4(5) (c) (ii), (iii) or (iv) (a private patient in a recognized hospital, a private patient in a private hospital or a private patient in a day hospital facility) may, if the person consents to the inclusion of those particulars for that purpose, include the following particulars for the purpose of a private health insurance claim in relation to the service:

(a)    the name of the private health insurance fund of which the person is a member;

(b)   the membership number or other unique identifier allocated to the person by the fund.

 

Subregulation 4(5B) provides that failure of the person to consent to the inclusion of their private health insurance details in the request for a pathology service does not affect any entitlement the person may have to a Medicare benefit, or a benefit payable by a private health insurance fund, in respect of the service.