Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (DIAGNOSTIC IMAGING SERVICES TABLE) REGULATIONS 2004 2004 NO. 307

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.

The Act provides, in part, for payments of Medicare benefits in respect of 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, including diagnostic imaging services, set out in prescribed tables.

Subsection 4AA(1) of the Act provides that the regulations may prescribe a table of diagnostic imaging services that sets out items of diagnostic imaging services, the amount of fees applicable in respect of each item and the rules for interpretation of the table. The Health Insurance (Diagnostic Imaging Services Table) Regulations 2003 (the 2003 Regulations) currently prescribe such a table.

Subsection 4AA(2) of the Act provides that, unless sooner repealed, regulations made under subsection 4AA(1) cease to be in force and are taken to be have been repealed on the day next following the 15^th sitting day of the House of Representatives after the end of a period of 12 months beginning on the day on which the regulations are notified in the Gazette. The 2003 Regulations were notified in the Gazette on 28 October 2003 and commenced on 1 November 2003.

The purpose of the Regulations is to prescribe a table of diagnostic imaging services for the 12-month period commencing on 1 November 2004. The new table effectively reproduces the table contained in the 2003 Regulations, with minor amendments to the rules of interpretation and the schedule of services and fees. The Regulations set out the items of diagnostic imaging services which are eligible for Medicare benefits, the amount of fees applicable in respect of each item and rules for interpretation of the table.

Medicare-funded diagnostic imaging services specified in the diagnostic imaging services table are managed through four "2003-2008 Quality and Outlays Memoranda of Understanding (MoUs)" between the Australian Government (as represented by the Department of Health and Ageing) and relevant diagnostic imaging profession representative bodies. The four MoUs cover radiology, cardiac imaging, nuclear medicine imaging and obstetric and gynaecological ultrasound.

The Radiology, Nuclear Medicine Imaging and Obstetric and Gynaecological Ultrasound MoU management committees have recommended amendments to 2003 Regulations, for inclusion in the Regulations. These committees include representatives from the Royal Australian and New Zealand College of Radiologists, the Australian Diagnostic Imaging Association, the Australian and New Zealand Association of Physicians in Nuclear Medicine and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

The Regulations provide for a 3% increase to the fee for radiology and nuclear medicine imaging services specified in Part 3 of Schedule 1 to the Regulations. The increase was recommended by the Radiology MoU Management Committee (RMC) and the Nuclear Medicine Imaging Consultative and Economics MoU Management Committee (NICEC), who met recently to review expenditure against agreed outlays in their respective MoUs. The increase brings expenditure back in line with agreed annual targets in the MoUs.

Details of the Regulations are provided 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 commence on 1 November 2004.

ATTACHMENT

DETAILS OF THE HEALTH INSURANCE (DIAGNOSTIC IMAGING SERVICES TABLE) REGULATIONS 2004

Regulation 1 provides for the Regulations to be referred to as the Health Insurance (Diagnostic Imaging Services Table) Regulations 2004.

Regulation 2 provides for the Regulations to commence on 1 November 2004.

Regulation 3 repeals the Health Insurance (Diagnostic Imaging Services Table) Regulations 2003 (as amended).

Regulation 4 defines, for the purpose of the Regulations, Act to mean the Health Insurance Act 1973 and this table to mean these Regulations.

Regulation 5 provides that the table of diagnostic imaging services and rules of interpretation are set out in set out in Schedule 1.

Schedule 1 - Table of diagnostic imaging services

In addition to remaking the Health Insurance (Diagnostic Imaging Services Table) Regulations 2003, the Diagnostic Imaging Services Table 2004:

•       makes amendments to four existing rules;

•       makes amendments to the description of one existing item; and

•       increases fees payable for certain items of radiology and nuclear medicine imaging by three percent.

Amendments to Part 2 - Rules of interpretation

Rule of interpretation 28 prescribes the meaning of amount for nuclear medicine imaging item 61642. "Amount" under rule 28 means (a) the fee set out in the item in Group I4, Part 3 of the table, in conjunction with which a service mentioned in item 61462 is performed; and (b) $125.05. In line with a three percent increase to the fee for nuclear medicine imaging services specified in Group I4, Part 3 of the table, the amount specified in rule 28(b) is increased to $129.00.

Rule of interpretation 29, subrule (2)(d), is amended by deleting "nearest higher amount" and inserting "nearest amount". Rule 29 specifies how the fee is calculated when multiple vascular ultrasound services are provided to the same patient on the same day. Subrule (2)(d) states that if a reduced fee calculated under subrule (1) is not a multiple of 5 cents, the reduced fee is taken to be the nearest higher amount, that is a multiple of 5 cents. The Health Insurance Commission has advised that if the reduced fee is not a multiple of 5 cents, the reduced fee is taken to be the nearest amount that is a multiple of 5 cents. This is consistent with the wording of subrule 38(3).

Rule of interpretation 30 prescribes the fee payable when multiple diagnostic imaging services are provided to the same patient on the same day. This rule is amended by:

(a)       specifying in subrule (6), that in addition to rule 29, rule 38 also applies to this rule;

(b)       inserting subrule (8) to specify that for rule 38 if a medical practitioner provides 2 or more MRI services described in subgroups 12 and 13 in Group I5, Part 3 of the table, for the same patient on the same day and one or more other diagnostic imaging services for that patient on that day, the amount of fees payable for the MRI services is taken, for the purposes of this rule, to be an amount payable for one diagnostic imaging service; and

(c)       renumbering the subrules following subrule 8.

Rule of interpretation 38 is amended by inserting subrules (2) and (3). Subrule 38(2) specifies that if two or more MRI services from subgroups 12 and 13 in Group I5, Part 3 of the table, are provided to the same patient on the same day, the fee for the items, other than the item with the highest fee, is reduced by 50%. Subrule 38(3) specifies how the fee is calculated if two or more applicable fees are equally the highest and if the reduced fee calculated under subrule (2) is not a multiple of 5 cents, the reduced fee is taken to be the nearest amount that is a multiple of 5 cents.

Part 3 - Services and Fees

Items 55028 to 55085, 55238 to 55603, 55800 to 58939, 59300 to 59970, 59763, 59974 to 60509 and 61109 are amended by increasing the fee for service by three percent. These items are included as part of the Radiology MoU. The Radiology MoU Management Committee (RMC) met in July 2004 and noted that Medicare expenditure for radiology services was tracking below agreed annual targets specified in the MoU. Therefore, the RMC recommended a three percent fee increase for radiology services to bring expenditure back in line with agreed annual targets in the MoU.

Items 61302 to 61499 are amended by increasing the amount of the fee for service by three percent. These items are included in the Nuclear Medicine Imaging MoU. The Nuclear Imaging Consultative and Economics MoU Management Committee (NICEC) met in August 2004 and noted that Medicare expenditure for nuclear medicine imaging services was tracking below agreed annual targets specified in the MoU. Therefore, the NICEC recommended a three percent fee increase for nuclear medicine imaging services to bring expenditure back in line with agreed annual targets in the MoU.

Obstetric and gynaecological ultrasound item 55729 is amended by making a minor change to the description of service to reflect current medical best practice and ultrasound technology.