Health Insurance (Allied Health and Dental Services) Determination HS/06/2004 (Cth)

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Health Insurance (Allied Health and Dental Services) Determination HS/06/2004

I, TONY ABBOTT, Minister for Health and Ageing, make this Determination under subsection 3C (1) of the Health Insurance Act 1973.

Dated 24 June 2004

TONY ABBOTT

Minister for Health and Ageing

Contents

Part 1Preliminary

1Name of Determination   2

2Commencement   2

3Interpretation   2

Part 2Allied health services

4Allied health services   3

5Application and interpretation   3

Part 3Dental health services

6Dental health services   5

7Application and interpretation   5

Schedule 1Allied health services   6

Schedule 2Dental health services   17

Part 1                 Preliminary

  1. Name of Determination

This Determination is the Health Insurance (Allied Health and Dental Services) Determination HS/06/2004.

  1. Commencement

This Determination commences on 1 July 2004.

  1. Interpretation

(1)   In this Determination:

Act means the Health Insurance Act 1973.

allied health service means a health service prescribed by regulation 3A of the Health Insurance Regulations 1975 that is specified in an item in Schedule 1.

dental health service means a dental service that is specified in an item in Schedule 2.

State includes the Northern Territory.

Note   The following terms are defined in subsection 3 (1) of the Act:

·      dental practitioner

·      general medical services table

·      medical practitioner

·      professional service.

(2)   For the purposes of this Determination, the Australian Capital Territory is taken to be part of the State of New South Wales.

Part 2                 Allied health services

  1. Allied health services

An allied health service is to be treated, for the purposes of the provisions relating to professional services and the provisions relating to medical services of the Health Insurance Act 1973 and regulations made under that Act, and the National Health Act 1953 and regulations made under that Act, as if:

(a)    it were both a professional service and a medical service; and

(b)    there were an item in the general medical services table that:

(i)    related to the service; and

(ii)    specified in respect of the service a fee in relation to each State, being the fee specified in the item in Schedule 1 relating to the service.

  1. Application and interpretation

(1)   In this Part and in Schedule 1:

eligible Aboriginal health worker means a person who is an eligible allied health professional in relation to the provision of an Aboriginal or Torres Strait Islander health service.

eligible allied health professional, in relation to the provision of an allied health service, means a person:

(a)    who is an allied health professional in relation to the provision of a service of that kind under subregulation 3A (2) of the Health Insurance Regulations 1975; and

(b)    whose name is entered in the register, kept by the Commission, of allied health professionals who are qualified to provide a service of that kind.

eligible audiologist means a person who is an eligible allied health professional in relation to the provision of an audiology health service.

eligible chiropodist means a person who is an eligible allied health professional in relation to the provision of a chiropody health service.

eligible chiropractor means a person who is an eligible allied health professional in relation to the provision of a chiropractic health service.

eligible dietitian means a person who is an eligible allied health professional in relation to the provision of a dietetics health service.

eligible mental health worker means a person who is an eligible allied health professional in relation to the provision of a mental health service.

eligible occupational therapist means a person who is an eligible allied health professional in relation to the provision of an occupational therapy health service.

eligible osteopath means a person who is an eligible allied health professional in relation to the provision of an osteopathy health service.

eligible physiotherapist means a person who is an eligible allied health professional in relation to the provision of a physiotherapy health service.

eligible podiatrist means a person who is an eligible allied health professional in relation to the provision of a podiatry health service.

eligible psychologist means a person who is an eligible allied health professional in relation to the provision of a psychology health service.

eligible speech pathologist means a person who is an eligible allied health professional in relation to the provision of a speech pathology health service.

EPC multidisciplinary care plan, in relation to a person, means an enhanced primary care multidisciplinary care plan for the person to which item 720, 722 or 730 of the general medical services table applies.

(2)   A reference in this Part or in Schedule 1 to a kind of health service is a reference to a service of that kind that is an allied health service.

Part 3                 Dental health services

  1. Dental health services

A dental health service is to be treated, for the purposes of the provisions relating to professional services and the provisions relating to medical services of the Health Insurance Act 1973 and regulations made under that Act, and the National Health Act 1953 and regulations made under that Act, as if:

(a)    it were both a professional service and a medical service; and

(b)    there were an item in the general medical services table that:

(i)    related to the service; and

(ii)    specified in respect of the service a fee in relation to each State, being the fee specified in the item in Schedule 2 relating to the service.

  1. Application and interpretation

In this Part and in Schedule 2:

dental assessment, in relation to a person, means a comprehensive assessment of the person’s dental health, and includes an evaluation of all teeth, their supporting structures and other oral tissues.

eligible dental practitioner means a dental practitioner whose name is entered in the register, kept by the Commission, of dental practitioners who can provide services to which any of items 10975, 10976 and 10977 apply.

eligible dental specialist means a person:

(a)    who is:

(i)    registered or licensed as a periodontist, endodontist, pedeodontist, or orthodontist under a law of a State or Territory; or

(ii)    registered or licensed as a dental specialist under a law of a State or Territory and recognised by the registering or licensing authority as a person who practises in the speciality of periodontics, endodontics, pedeodontics, or orthodontics; and

(b)    whose name is entered in the register, kept by the Commission, of dental specialists who can provide services to which item 10977 applies.

EPC multidisciplinary care plan, in relation to a person, means an enhanced primary care multidisciplinary care plan for the person to which item 720, 722 or 730 of the general medical services table applies.


Schedule 1        Allied health services

(section 4)

Item Service Fee ($)
10950

Aboriginal or Torres Strait Islander health service provided to a person by an eligible Aboriginal health worker if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible Aboriginal health worker by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible Aboriginal health worker gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75
10952

Audiology health service provided to a person by an eligible audiologist if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible audiologist by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible audiologist gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75
10954

Dietetics health service provided to a person by an eligible dietitian if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible dietitian by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible dietitian gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75
10956

Mental health service provided to a person by an eligible mental health worker if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible mental health worker by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible mental health worker gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75
10958

Occupational therapy health service provided to a person by an eligible occupational therapist if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible occupational therapist by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible occupational therapist gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75
10960

Physiotherapy health service provided to a person by an eligible physiotherapist if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible physiotherapist by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible physiotherapist gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75
10962

Chiropody health service provided to a person by an eligible chiropodist, or podiatry health service provided to a person by an eligible podiatrist, if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible chiropodist or eligible podiatrist by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible chiropodist or eligible podiatrist gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75
10964

Chiropractic health service provided to a person by an eligible chiropractor if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible chiropractor by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible chiropractor gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75
10966

Osteopathy health service provided to a person by an eligible osteopath if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible osteopath by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible osteopath gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75
10968

Psychology health service provided to a person by an eligible psychologist if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible psychologist by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible psychologist gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75
10970

Speech pathology health service provided to a person by an eligible speech pathologist if:

   (a)  the service is provided to a person who has a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible speech pathologist by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  the service is provided to the person individually and in person; and

   (f)  the service is of at least 20 minutes duration; and

   (g)  after the service, the eligible speech pathologist gives a written report to the referring medical practitioner; and

   (h)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 5 services (including any services to which this item or any other item in this Schedule applies) in a 12 month period

 51.75

Schedule 2        Dental health services

(section 6)

Item Service Fee ($)
10975

Dental assessment provided to a person by an eligible dental practitioner if:

   (a)  the service is provided to a person whose dental condition is exacerbating a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the person is referred to the eligible dental practitioner by the medical practitioner using a referral form issued by the Commission; and

   (d)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (e)  after the assessment, the eligible dental practitioner gives a written report to the referring medical practitioner; and

   (f)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 3 services (including any services to which this item or item 10976 or 10977 applies) in a 12 month period

 86.25
10976

Dental treatment provided to a person by an eligible dental practitioner if:

   (a)  the service is provided to a person whose dental condition is exacerbating a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the service is associated with a service of the kind described in item 10975 previously provided to the person; and

   (d)  the person is referred to the eligible dental practitioner by the medical practitioner using a referral form issued by the Commission; and

   (e)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (f)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 3 services (including any services to which this item or item 10975 or 10977 applies) in a 12 month period

 86.25
10977

Dental service provided to a person by an eligible dental practitioner or an eligible dental specialist (the providing dentist) if:

   (a)  the service is provided to a person whose dental condition is exacerbating a chronic and complex condition that is being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under an EPC multidisciplinary care plan; and

   (b)  the service is recommended in the person’s EPC multidisciplinary care plan as part of the management of the person’s chronic and complex condition; and

   (c)  the service is associated with a service of the kind described in item 10975 previously provided to the person by another eligible dental practitioner; and

   (d)  the person is referred to the providing dentist by the eligible dental practitioner who provided the service described in item 10975 using a referral form issued by the Commission; and

   (e)  the person is not an admitted patient of a hospital or day‑hospital facility; and

   (f)  after the service, the providing dentist gives a written report to the referring eligible dental practitioner and the medical practitioner mentioned in paragraph (a); and

   (g)  in the case of a service in respect of which a private health insurance benefit is payable — the person who incurred the medical expenses in respect of the service has elected to claim the medicare benefit in respect of the service, and not the private health insurance benefit —

to a maximum of 3 services (including any services to which this item or item 10975 or 10976 applies) in a 12 month period

 86.25
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