Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE AMENDMENT REGULATIONS 2003 (NO. 1) 2003 NO. 87

STATUTORY RULES 2003 No. 87

Issued by the Authority of the Minister for Health and Ageing

Health Insurance Act 1973

Health Insurance Amendment Regulations 2003 (No. 1)

Section 133 of the Health Insurance Act 1973 (the Act) provides that the Governor-General may make Regulations prescribing matters for the purposes of the Act.

The Act provides for payments of Medicare benefits in respect of professional services rendered to eligible persons.

The Health Insurance Amendment (Diagnostic Imaging, Radiation Oncology and Other Measures) Act 2003 (the Amending Act) makes a number of amendments to the Act in relation to the payment of Medicare benefits for diagnostic imaging and radiation oncology services. The main purposes of the amendments are to require the registration of diagnostic imaging and radiation oncology practice sites and the allocation of Location Specific Practice Numbers to these practices in order for Medicare benefits to be payable; implement recommendations of the Diagnostic Imaging Referral Arrangements Review in relation to the referral arrangements for diagnostic imaging services; and restore referral access for osteopaths for diagnostic imaging services.

The purpose of the Regulations is to reflect changes to the Act relating to Medicare benefits and referral arrangements as they apply to diagnostic imaging and radiation oncology services.

The Regulations:

•       define a radiation oncology service by reference to items in the General Medical Services Table;

•       require the LSPN to be recorded on accounts/receipts and bulk billing forms;

•       prescribe information, additional to the primary information set out in the Amending Act, that would be required in an application for registration and be recorded on the register; and

•       prescribe equipment 'types' for the purpose of establishing the payment of the correct Medicare benefit where the type of equipment used affects the payment of Medicare benefits, for example, computed tomography equipment over and under 10 years old.

Under the referral arrangements amendments, providers would be able to substitute a service for the service originally requested where they form the opinion that the service being substituted would be more clinically appropriate for the diagnosis of the patient's condition. Before they do this, however, they must have consulted with, or have taken all reasonable steps to consult with, the practitioner who requested the service.

To identify when a service has been substituted, the Regulations would require providers to endorse on accounts/receipts and bulk billing forms the letters 'SS' to indicate they have substituted the service for another. The Regulations would also require providers to record in their clinical records words to the effect that they have either consulted with, or have taken all reasonable steps to consult with, the requesting practitioner.

Osteopaths are now recognised as a separate profession for the purpose of requesting prescribed diagnostic imaging services.

The Regulations prescribe the services osteopaths can request. The services would be the same as those that can be currently requested by physiotherapists and chiropractors.

Details of the Regulations are outlined in the attachment.

The Regulations commenced on gazettal.

DETAILS OF THE HEALTH INSURANCE AMENDMENT REGULATIONS 2003 (No. 1)

Regulation 1 provides that the name of the Regulations would be the Health Insurance Amendment Regulations 2003 (No. 1).

Regulation 2 provides that, subject to the transitional provisions as set out in Regulation 4, the Regulations commence on gazettal.

Regulation 3 provides that the Health Insurance Regulations 1975 are to be amended by the provisions in Schedule 1 of the Regulations.

Regulation 4 provides that the amendments set out in Items 6 and 7 of Schedule 1 would apply from a date to be proclaimed or 6 months after Royal Assent if no earlier date is proclaimed. Items 6 and 7 prescribe certain extra particulars that would need to be recorded on accounts/receipts or assignment of benefit forms for diagnostic imaging and radiation oncology services in order for Medicare benefits to be payable.

Schedule 1

Item 1

The Regulation amends the definition of 'requester number' in current Regulation 2 of the Regulations to include a reference to osteopaths.

This amendment is a consequence of the amendments to the Act to introduce osteopaths as a further class of practitioners that are able to request 'R' Type diagnostic imaging services under the Medicare arrangements.

Up until now, only osteopaths registered as chiropractors under state or territory registration laws could request specified diagnostic imaging services under the Medicare arrangements.

Requester numbers are issued by the Health Insurance Commission to practitioners who are able to request diagnostic imaging services where those practitioners do not have Medicare provider numbers.

Item 2

This item proposes to amend the heading of current Regulation 11. Regulation 11 prescribes the 'R' Type diagnostic imaging services that can be requested by chiropractors, physiotherapists and podiatrists.

The amendment in Item 2 includes a reference to osteopaths in the heading of Regulation 11 as a consequence of those practitioners now being able to request certain R Type diagnostic imaging services. See also Item 3.

Section 16B of the Act contains the provisions that set out which practitioners are able to request diagnostic imaging services. It also limits the services able to be requested by ancillary practitioners to those services prescribed in the Regulations. Subsections 16B(3), (3A) and (3B) are the limiting provisions for chiropractors, physiotherapists and podiatrists respectively.

This amendment is a consequence of introduction of osteopaths as a further class of practitioner that are able to request 'R' Type diagnostic imaging services under the Medicare arrangements.

Item 3

As mentioned in Item 2, Regulation 11 currently prescribes the 'R' Type diagnostic imaging services that can be requested by chiropractors, physiotherapists and podiatrists.

Sub-regulation 1 of Regulation 11 prescribes the items that can be requested by chiropractors and physiotherapists. The current prescribed items are: 57712, 57715 and 58100 to 58115 (inclusive). They relate to x-rays of the hip, pelvic girdle and spine.

By adding subsection 16B(3C) to subregulation 1, the amendment made by Item 3 would have the effect of prescribing the items mentioned above as services that osteopaths would be able to request. Subsection 16B(3C) is the relevant provision in the Act that allows for the prescribing of services that osteopaths are able to request.

Effectively, the amendment would restore referral access to these services for those osteopaths previously registered as chiropractors under State and Territory legislation and who were disenfranchised through changes in the registration laws.

It would also give requesting rights to osteopaths not previously registered as chiropractors under those laws.

Item 4

This amendment relates to the Location Specific Practice Number (LSPN) arrangements for radiation oncology practices.

Subsection 16F(2) mentioned in the amendment is a new provision inserted into the Act by the Amending Act. In association with the definition of 'radiation oncology service' and subsection 16F(3) inserted by the Amending Act, subsection 16F(2) allows for a definition of a radiation oncology service to be prescribed in the Regulations by reference to items in the general medical services table.

The purpose of these provisions is to define the services to be covered by the LSPN arrangements for radiation oncology practices.

Radiation oncology practices with radiation oncology equipment that is used in the rendering of the prescribed services would need to be registered in order for Medicare benefits to be payable for the services.

The items to be prescribed are the 'megavoltage', 'computerised planning' and 'brachytherapy' items currently listed in the Medicare Benefits Schedule. These are items that are performed in specialist radiation oncology practices.

They do not include the superficial, orthovoltage and stereotactic items. Practices with equipment used for these items only do not need to register under the LSPN arrangements.

The rationale for including megavoltage, computerised planning and brachtherapy items only is that the LSPN arrangements for radiation oncology practices are primarily designed to streamline the current Health Program Grants arrangements. It is only this type of equipment that attracts funding under the Health Program Grants arrangements.

Item 5

The amendment to subregulation 13(15) is consequence of osteopaths now being able to request diagnostic imaging services.

Regulation 13 prescribes the particulars that must be shown on accounts/receipts and assignment of benefit forms in order for Medicare benefits to be payable. Subregulation 13(14), in association with subregulation 13(15), prescribes additional particulars for diagnostic imaging services, including details of the requesting practitioner. These details include either the provider number/requester number or the practice address of the requesting practitioner.

The amendment would mean that the requester number allocated to osteopaths by the Health Insurance Commission would be a prescribed particular to be included on accounts/receipts and assignment of benefit forms for diagnostic imaging services where the practice address of the osteopath was not provided.

Item 6

This item proposes to introduce a new subregulation into Regulation 13. As mentioned earlier, Regulation 13 prescribes the particulars that must be shown on accounts/receipts and assignment of benefit forms in order for Medicare benefits to be payable.

The new subregulation 13(17) results from provisions in the Amending Act which, under specified circumstances, now allow providers of diagnostic imaging services to substitute a more appropriate service in place of the service originally requested.

Under the new subregulation, accounts/receipts and assignment of benefit forms would need to show the letters 'SS' where a service has been substituted.

As provided for in the Transitional provisions in Clause 4 of the amending instrument, this new subregulation comes into effect on a date to be proclaimed. It means that 'SS' would only be required on claims documents for services rendered on or after the date of proclamation.

Item 7

Like Item 6, this item proposes to inserts a new subregulation requiring certain particulars to be recorded on accounts/receipts and assignment of benefit forms.

The new subregulation 13(21) would provide that the Location Specific Practice Number for the registered practice where the diagnostic imaging procedure (ie the capturing of the images, eg x-ray film, ultrasound scan, computed tomography scan etc) is undertaken would need to be recorded on the documents supporting a Medicare claim.

Items 8

This item proposes to make a minor amendment to subparagraph 20(2)(c)(i) to recognise that osteopaths as practitioners who are able to request certain diagnostic imaging services.

Subparagraph 20(2)(c)(i) specifies the records that must be kept when a request has been lost.

Item 9

The item proposes to make a minor amendment to subparagraph 20(2)(c)(iii) in order to enable the addition of the new paragraph in Item 10.

Item 10

This item relates to the new substituted service provisions introduced by the Amending Act, ie subsection 16(10A).

Subsection 16(10A) provides that, before substituting a service, the provider must have either consulted with the requesting practitioner, or have taken all reasonable steps to do so they were unable to contact the requesting practitioner.

The item proposes to amend Regulation 20. As mentioned under Item 8, Regulation 20 provides for records that must be kept by providers of diagnostic imaging services.

The amendment would require records to be kept to support the consultation requirements set out in subsection 16(10A).

Item 11

This item proposes to introduce 6 new Regulations to support the Location Specific Practice Number (LSPN) arrangements introduced by the Amending Act.

Regulations 20A, 20B and 20C apply to diagnostic imaging practices. Regulations 20D, 20E and 20F apply to radiation oncology practices.

Regulation 20A

Regulation 20A would prescribe additional information to that set out in the Amending Act (Section 23DZP) which is required to be included in an application for registration as a diagnostic imaging practice.

Paragraph (a) would require information to be supplied about the nature of the practice. As indicated in the example shown, the information that may be collected under this paragraph could include whether the practice is a base for mobile equipment, a specialist diagnostic imaging medical practice (either on a stand-alone practice site or co-located with a primary care practice of group), a primary care practice, a sports medicine clinic or a public hospital.

Paragraph (b) would require information to be provided about the types of equipment ordinarily located at the practice. It would include such things as the number of each type of equipment, the age of the equipment where there are Medicare eligibility requirements in relation to the equipment (eg computed tomography equipment), the functionality of the equipment (eg for ultrasound equipment, whether the equipment has an echocardiography capability), and identifying numbers such as serial number.

Regulation 20B

This regulation proposes to prescribe the additional information to that set out in Section 23DZQ of the Amending Act that is to be included on the diagnostic imaging register.

It is that this be the same information as new regulation 20A above.

Regulation 20C

Diagnostic imaging equipment would be recorded on the register by type. The purpose of recording equipment by type is to ensure that a practice has equipment that is appropriate for use in the rendering of particular diagnostic imaging services.

Using the ultrasound equipment type 'ultrasound equipment - musculoskeletal' in paragraph (b) as an example, the diagnostic imaging services referred to in that paragraph require the use of an ultrasound transducer which can operate with a frequency of at least 7.5 megahertz in order for Medicare benefits to be payable for those services. The items requiring the use of a 7.5Mhz transducer are those currently listed in subgroup 6 of Group I1 in the diagnostic imaging services table, hence the reference to those items in the paragraph.

Each of the equipment types prescribed similarly link to particular diagnostic imaging services. In relation to paragraph (f) - 'nuclear medicine equipment for positron emission tomography', the Health Insurance Determinations referred to are determinations made under section 3C of the Act. This section allows the Minister to determine that additional services to those listed in the Medicare Benefits Schedule can attract Medicare benefits.

A further significance of prescribing equipment types is that any changes in the type of equipment recorded on the register for a diagnostic imaging practice need to be notified to the Health Insurance Commission within 28 days of the change occurring. This is because equipment type information is regarded as 'primary information' under section 23DZR of the Amending Act.

Regulations 20D, 20E and 20F

These Regulations mirror Regulations 20A, 20B and 20C in relation to radiation oncology practices.