Commonwealth Numbered Regulations Commonwealth Numbered Regulations
[1] Regulation 1
substitute
1 Name of Regulations
These Regulations are the Human Services (Medicare) Regulations 1975 .
[2] Regulation 3
substitute
3 Definitions
In these Regulations:
"Act" means the Human Services (Medicare) Act 1973 .
"Aged Care Act" means the Aged Care Act 1997 .
"approved supplier" has the meaning given by subsection 84 (1) of the National Health Act.
emergency means an emergency or disaster that occurs in Australia, or that affects one or more Australian citizens or permanent residents, and includes:
(a) an emergency or disaster that has been the subject of a declaration under section 80J or 80K of the Privacy Act 1988 ; or
(b) any circumstance in relation to which the Australian Government has decided that a program of special assistance involving the provision of a service, benefit, program or facility is to be implemented.
Examples
1 A natural disaster.
2 A terrorist act.
healthcare providers includes:
(a) medical practitioners; and
(b) prescribers; and
(c) pharmacists; and
(d) approved suppliers; and
(e) dentists; and
(f) State and Territory health departments; and
(g) State and Territory mental health authorities; and
(h) private and public pain management clinics; and
(i) private and public alcohol or drug detoxification centres; and
(j) private and public hospitals.
"Health Department" means the Department administered by the Minister administering the National Health Act.
"Health Insurance Act" means the Health Insurance Act 1973 .
"Health Secretary" means the Secretary of the Health Department.
"lifetime health cover" has the meaning given by section 31-1 of the Private Health Insurance Act.
"National Health Act" means the National Health Act 1953 .
"PBS information" means information collected for the administration of the Pharmaceutical Benefits Scheme established under Part VII of the National Health Act.
"person affected by an emergency" has a meaning affected by regulation 3A.
"personal information" has the meaning given by subsection 6 (1) of the Privacy Act 1988 .
"Pharmaceutical Benefits Regulations" means the National Health (Pharmaceutical Benefits) Regulations 1960 .
"Private Health Insurance Act" means the Private Health Insurance Act 2007 .
"reappraisal period" is the period under section 27-2 of the Aged Care Act in which a reappraisal of the classification of the level of care needed by an aged care recipient must be made.
State or Territory body means:
(a) a State or Territory Minister; or
(b) a Department of a State or Territory; or
(c) a body (whether incorporated or not) established for a public purpose under a law of a State or Territory.
[3] Regulation 3A
substitute
3A Person affected by an emergency
In these Regulations, a reference to a person affected by an emergency includes:
(a) a person who is indirectly affected by the emergency; and
(b) an individual who has a family member who is directly or indirectly affected by the emergency; and
(c) an unincorporated organisation that is directly or indirectly affected by an emergency.
[4] Paragraph 9 (3) (g)
omit
section 15.12
insert
section 15.12, 15.20 or 15.33
[5] Paragraph 12 (b)
substitute
(b) on behalf of the Health Secretary, to make information about an aged care service publicly available as permitted by subsections 86-9 (1) and (2) of the Aged Care Act.
[6] Part 3
substitute
Part 3 Prescribed functions -- general
18 Prescribed functions
For paragraph 5 (1) (e) of the Act, this Part prescribes functions of the Chief Executive Medicare.
19 Delegated functions
(1) A prescribed function is to perform functions delegated to the Chief Executive Medicare under:
(a) a law of the Commonwealth; or
(b) a law of a State or Territory.
(2) Paragraph (1) (b) applies only if the Chief Executive Medicare is allowed by sections 8AD and 8AE of the Act to perform the function.
20 Functions in relation to prescription shopping
(1) A prescribed function is to detect and prevent prescription shopping, which includes the functions mentioned in this regulation.
(2) The Chief Executive Medicare may use PBS information (including personal information) for the performance of the functions mentioned in this regulation.
(3) The education and prevention function is to:
(a) promote awareness of the Prescription Shopping Program to healthcare providers, prescription shoppers and the general public; and
(b) promote measures to assist healthcare providers to manage prescription shoppers or people who may be at risk of prescription shopping; and
(c) educate healthcare providers and prescription shoppers about the law and requirements within which the Prescription Shopping Program operates; and
(d) encourage prescription shoppers to have a nominated prescriber; and
(e) encourage prescribers to become nominated prescribers; and
(f) encourage communication between prescribers, approved suppliers and pharmacists; and
(g) discourage inefficient and improper use of pharmaceutical benefits.
(4) The identification and detection function is to:
(a) identify prescription shoppers, prescribers prescribing pharmaceutical benefits to prescription shoppers and approved suppliers supplying pharmaceutical benefits to prescription shoppers; and
(b) establish and maintain databases containing information about prescription shoppers; and
(c) detect and identify prescription shoppers who may be improperly using, stockpiling, swapping, diverting or illegally dealing with pharmaceutical benefits.
(5) The disclosure function is to:
(a) disclose PBS information about whether a person is or is not a prescription shopper; and
(b) disclose PBS information about a prescription shopper to:
(i) the prescription shopper; and
(ii) a prescriber, to assist the prescriber to make decisions about prescribing to a prescription shopper who has visited or is visiting that prescriber or is a patient of that prescriber; and
(iii) an approved supplier who is proposing to supply, or has supplied, pharmaceutical benefits to the prescription shopper, to assist the approved supplier (or a pharmacist employed by the approved supplier) to make decisions about supplying pharmaceutical benefits to that prescription shopper.
(6) The Chief Executive Medicare may perform the disclosure function for the following purposes:
(a) administering and enforcing the Chief Executive Medicare's functions under the National Health Act;
(b) protecting public revenue;
(c) discouraging inefficient and improper use of pharmaceutical benefits.
(7) The evaluation and reporting function is to use PBS information and information collected by the Chief Executive Medicare under the National Health Act to:
(a) evaluate the Prescription Shopping Program; and
(b) report (using de-identified PBS information) to the Health Department and other bodies on the administration and outcomes of the Program.
(8) In this regulation:
"nominated prescriber" , in relation to a prescription shopper, means a prescriber nominated by the prescription shopper from time to time to be that person's main prescriber.
"prescriber" means a person who is authorised to prescribe a pharmaceutical benefit or purports to be authorised to prescribe a pharmaceutical benefit.
"prescription shopper" has the meaning given by subregulation (9).
"Prescription Shopping Program" means the program administered by the Department and the Health Department to reduce doctor shopping.
target pharmaceutical benefits means pharmaceutical benefits in any of the following categories of the Anatomical Therapeutic Chemical classification system:
(a) N02 (Analgesics);
(b) N03 (Antiepileptics);
(c) N04 (Anti-Parkinson Drugs);
(d) N05 (Psycholeptics);
(e) N06 (Psychoanaleptics);
(f) N07 (Other central nervous system drugs);
(g) R03 (Drugs for obstructive airway diseases);
(h) C10A (Serum lipid reducing agents);
(i) A02B (Drugs for peptic ulcer and gastro-oesophageal reflux diseases);
(j) J01 (Antibacterials for systemic use);
(k) M01 (Anti-inflammatory and antirheumatic products);
(l) A10A (Insulin and analogues);
(m) C02 (Antihypertensives).
Note The Anatomical Therapeutic Chemical classification system is published by the World Health Organisation's Collaborating Centre for Drug Statistics Methodology.
(9) In this regulation, prescription shopper means a person who, within any 3 month period:
(a) has had supplied to him or her pharmaceutical benefits prescribed by 6 or more different prescribers; or
(b) has had supplied to him or her a total of 25 or more target pharmaceutical benefits; or
(c) has had supplied to him or her a total of 50 or more pharmaceutical benefits.
(10) Paragraph (9) (a) does not include a prescriber who is a specialist within the meaning of subsection 3 (1) of the Health Insurance Act and who has prescribed pharmaceutical benefits to a person in that capacity.
21 Functions in relation to provision of emergency services
(1) The following are prescribed functions:
(a) providing a service, benefit, program or facility to a person affected by an emergency (an emergency service );
(b) participating in disaster policy and planning activities, including activities undertaken by disaster policy and planning committees.
(2) Without limiting subregulation (1), the Chief Executive Medicare may perform the functions for, or under an arrangement with, a State or Territory body.
(3) The function mentioned in paragraph (1) (a) includes the following:
(a) establishing and maintaining a register of persons affected by the emergency;
(b) receiving, processing, investigating, deciding and paying claims for assistance;
(c) operating a telephone enquiry line;
(d) providing call centre assistance;
(e) making arrangements for health assessments and other assistance in relation to health care;
(f) referring a person to another organisation if the person requires assistance provided by that organisation;
(g) working with, and providing information to, other government and non-government bodies in relation to the provision of assistance;
(h) providing information to a State or Territory body about a person affected by the emergency that will assist the State or Territory body to provide a payment, benefit or other assistance to the person;
(i) undertaking action (including starting legal proceedings) to recover payments that should not have been made;
(ij) disclosing statistical information (including de-identified information from the register mentioned in paragraph (a)) about assistance provided;
(k) undertaking compliance, audit, review, investigation, enforcement and recovery services ancillary to the emergency service.
(4) Information in subregulation (3) includes personal information.
(5) If the Chief Executive Medicare provides an emergency service to a person, or the person makes a request for an emergency service, the Chief Executive Medicare may:
(a) collect information about the person or the person's family, including personal information; and
(b) maintain records about the emergency service or the request.
22 Functions in relation to aged care payments
The following are prescribed functions:
(a) making payments as directed by the Health Department to a proprietor of eligible premises under section 56 of the National Health Act;
(b) making payments in relation to residential care services under section 60 of the Aged Care (Consequential Provisions) Act 1997 ;
(c) undertaking action (including starting legal proceedings) to recover any amount paid under paragraph (a) or (b) that is an overpayment.
23 Function in relation to lifetime health cover
(1) A prescribed function is to assist the Health Department with communications to members of the public about lifetime health cover.
(2) This function includes:
(a) identifying persons who have become subject to, or will soon become subject to, the operation of lifetime health cover; and
(b) providing persons identified under paragraph (a) with information about lifetime health cover received by the Chief Executive Medicare from the Health Department; and
(c) providing information and reports on matters relating to lifetime health cover to the Health Department.
(3) In performing this function, the Chief Executive Medicare may use personal information collected for the performance of the medicare functions.
24 Functions in relation to inappropriate practices
(1) The following are prescribed functions:
(a) devising and implementing measures to:
(i) prevent practitioners and other persons from engaging in inappropriate practice; and
(ii) detect cases where practitioners or other persons have engaged in inappropriate practice in relation to rendering or initiating services; and
(iii) prevent or detect activities relating to claims for medicare benefits, or receipt of medicare benefits, that may constitute an offence under the Health Insurance Act, the Crimes Act 1914 or the Criminal Code ;
(b) if there are reasonable grounds to suspect that a person has engaged in inappropriate practice, investigating the conduct of the person to decide whether to make a request under subsection 86 (1) of the Health Insurance Act for the provision of services by the person to be reviewed;
(c) investigating cases where there are reasonable grounds to suspect that:
(i) an act in relation to a claim for medicare benefits, or receipt of medicare benefits, may constitute an offence under the Health Insurance Act, the Crimes Act 1914 or the Criminal Code ; or
(ii) a person may have committed an offence against section 23DP, 106D or 106EA, or subsection 19D (2), 19D (7), 106E (1) or 106E (2), of the Health Insurance Act;
(d) if an investigation under paragraph (c) discloses enough evidence for a prosecution, referring the case and the evidence to the Australian Federal Police or the Director of Public Prosecutions;
(e) undertaking action (including starting legal proceedings) to recover from a person an amount of medicare benefit that is recoverable by the Commonwealth, including under the Health Insurance Act.
(2) In this regulation:
"inappropriate practice" has the meanings given by section 82 of the Health Insurance Act.
"practitioner" has the meaning given by section 81 of the Health Insurance Act.
"service" has the meaning given by section 81 of the Health Insurance Act.
25 Functions in relation to provision of pharmaceutical benefits
The following are prescribed functions:
(a) processing claims for payment relating to the provision of pharmaceutical benefits under Part VII of the National Health Act , and making payments of those claims;
(b) on behalf of the Repatriation Commission, processing claims for payment relating to the provision of pharmaceutical benefits under the Veterans' Entitlements Act 1986 and the Australian Participants in British Nuclear Tests (Treatment) Act 2006 , and making payments of those claims;
(c) on behalf of the Military Rehabilitation and Compensation Commission, processing claims for payment relating to the provision of pharmaceutical benefits under the Military Rehabilitation and Compensation Act 2004 , and making payments of those claims;
(d) devising and implementing measures to prevent or detect contraventions of Part VII of the National Health Act or the Pharmaceutical Benefits Regulations;
(e) investigating cases where there are reasonable grounds to suspect that an act in relation to the provision of a pharmaceutical benefit may constitute an offence under the National Health Act, the Pharmaceutical Benefits Regulations, the Crimes Act 1914 or the Criminal Code ;
(f) if an investigation under paragraph (e) discloses enough evidence for a prosecution, referring the case and the evidence to the Australian Federal Police or the Director of Public Prosecutions;
(g) undertaking action (including starting legal proceedings) to recover from a person an amount relating to a pharmaceutical benefit that is recoverable by the Commonwealth, including under the National Health Act or the Pharmaceutical Benefits Regulations.
26 Functions in relation to hearing services
(1) The following are prescribed functions:
(a) acting as the claims acceptance body for section 21 of the Hearing Services Administration Act 1997 ;
(b) acting as the claims payment body for that section.
(2) Subregulation (1) has effect only when a declaration that the Chief Executive Medicare is the claims acceptance body or the claims payment body for the purposes of section 21 of the Hearing Services Administration Act 1997 is in force.
(3) Each of the functions in subregulation (1) includes:
(a) recovering a service provider debt under section 24 of the Hearing Services Administration Act 1997 if:
(i) the debt is apparent from the records of the Chief Executive Medicare; or
(ii) the Health Department notifies the Chief Executive Officer of the debt; and
(b) disclosing the following information to the Health Department about a claim accepted or paid by the Chief Executive Medicare:
(i) client number;
(ii) voucher number;
(iii) date on which the claim was submitted;
(iv) date on which the claim was processed;
(v) date of the service to which the claim relates;
(vi) provider number;
(vii) practitioner number;
(viii) site identification;
(ix) item number;
(x) hearing loss details for right and left ears;
(xi) details of the device fitted to the client, whether fitted to the left or right ear, and fitting configuration;
(xii) date on which the device was fitted;
(xiii) details of top-up devices;
(xiv) contracted service provider's certification details;
(xv) client certification details;
(xvi) cost to the client;
(xvii) payment details;
(xviii) a code showing the reason a claim or an element of a claim was rejected;
(xix) any other details about the processing of the claim.
(4) In this regulation:
"client" means a person who received a hearing service for which a claim has been made.
"contracted service provider" has the meaning given by section 4 of the Hearing Services Administration Act 1997 .
"hearing services" has the meaning given by section 4 of the Hearing Services Administration Act 1997 .
"voucher" has the meaning given by section 4 of the Hearing Services Administration Act 1997 .
27 Functions in relation to military compensation
The following are prescribed functions:
(a) processing, on behalf of the Military Rehabilitation and Compensation Commission, claims for compensation under Chapter 6 of the Military Rehabilitation and Compensation Act 2004 ;
(b) making payments for those claims.
28 Functions in relation to claims for treatment provided under certain legislation
The following are prescribed functions:
(a) processing, on behalf of the Repatriation Commission and the Military Rehabilitation and Compensation Commission, claims for payment in relation to:
(i) the provision of medical treatment under Division 2 of Part IV of the Seamen's War Pensions and Allowances Regulations, as in force on 30 June 1994; and
(ii) the provision of treatment under the following Acts:
(A) Australian Participants in British Nuclear Tests (Treatment) Act 2006 ;
(B) Military Rehabilitation and Compensation Act 2004 ;
(C) Safety, Rehabilitation and Compensation Act 1988 ;
(D) Veterans' Entitlements Act 1986 ;
(b) making payments for those claims.
29 Function in relation to registration of sonographers
A prescribed function is to establish and maintain a register of sonographers.
30 Function in relation to mental health care by medical practitioners
A prescribed function is to establish and maintain a register of medical practitioners who may provide focused psychological strategies under the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule Initiative administered by the Health Department.
31 Functions in relation to allocation of identification numbers
The following are prescribed functions:
(a) allocating identification numbers for the purposes of the National Health Act to medical practitioners and to participating dental practitioners;
(b) allocating identification numbers for the purposes of the Health Insurance Act to the following persons in relation to the person's places of practice:
(i) practitioners;
(ii) approved pathology practitioners;
(iii) participating midwives;
(iv) participating nurse practitioners;
(v) participating optometrists;
(vi) persons providing health services determined under section 3C of that Act.
Part 4 Miscellaneous
32 Prescribed period
For paragraph 41C (8) (a) of the Act, the prescribed period is the period of 2 years that commenced on 1 January 1981.
[7] Further amendments -- Chief Executive Officer
The following provisions are amended by omitting each mention of 'Chief Executive Officer' and inserting 'Chief Executive Medicare':
* regulations 5 to 17.