Health Insurance (Optical Coherence Tomography) Determination 2016 (Cth)

Health Insurance (Optical Coherence Tomography) Determination 2016

I, ANDREW STUART, delegate of the Minister for Health and Aged Care, make this Determination under subsection 3C(1) of the Health Insurance Act 1973. 

Dated           Thirty-first                October 2016

ANDREW STUART
DEPUTY SECRETARY
HEALTH BENEFITS GROUP
DEPARTMENT OF HEALTH

Contents

1.           Name of Determination

2.           Commencement

3.           Authority

4.           Schedules

5.           Definitions

6.           Treatment of relevant services

Schedule 1 – relevant services

Schedule 2 – relevant services

Schedule 3 – amendments

Part 1

1. Name of Determination

This Determination is the Health Insurance (Optical Coherence Tomography) Determination 2016.

1. Commencement

Commencement information
Column 1	Column 2	Column 3
Provisions	Commencement	Date/Details
1. Sections 1 to 6 and Schedule 1	1 November 2016.	1 November 2016
2.  Schedules 2 and 3	1 December 2016.	1 December 2016

1. Authority

This Determination is made under subsection 3C(1) of the Health Insurance Act 1973.

1. Schedules

Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.

1. Definitions

1. In this Determination:

   Act means the Health Insurance Act 1973.

   pharmaceutical benefits scheme means the scheme for the supply of pharmaceutical benefits established under Part VII of the National Health Act 1953.

   relevant provisions means all provisions, of the Act and regulations made under the Act, and the National Health Act 1953 and regulations made under that Act, relating to medical services, professional services or items.

   relevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in a Schedule.

   Schedule means a Schedule to this Determination.

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

   ·clinically relevant

   ·general medical services table

(2)    Unless the contrary intention appears, a reference in this Determination to a provision of the Act or the National Health Act 1953 or regulations made under the Act or under the National Health Act 1953 as applied, adopted or incorporated in relation to specifying a matter is a reference to those provisions as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.

1. Treatment of relevant services

For subsection 3C(1) of the Act a relevant service, provided in accordance with this Determination and as a clinically relevant service, is to be treated, for the relevant provisions, 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 for the service a fee in relation to each State, being the fee specified in the Schedule in relation to the service.

Schedule 1 – relevant services

Group D1—Miscellaneous diagnostic procedures and investigations
Item	Service	Fee ($)
Subgroup 2—Ophthalmology
11219	Optical coherence tomography to determine if the requirements relating to: a)    age related macular degeneration for access to initial treatment with ranibizumab or aflibercept, or b)    diabetic macular oedema for access to initial treatment with ranibizumab, aflibercept or dexamethasone, or c)    central retinal vein occlusion for access to initial treatment with ranibizumab or aflibercept, or d)    branch retinal vein occlusion for access to initial treatment with ranibizumab under the pharmaceutical benefits scheme are fulfilled. Maximum of one service in a 12 month period	40.00

Schedule 2 – relevant services

Group D1—Miscellaneous diagnostic procedures and investigations
Item	Service	Fee ($)
Subgroup 2—Ophthalmology
11219	Optical coherence tomography to determine if the requirements relating to: a)   age related macular degeneration for access to initial treatment with ranibizumab or aflibercept; or b)   diabetic macular oedema for access to initial treatment with ranibizumab, aflibercept or dexamethasone; or c)   central or branch retinal vein occlusion for access to initial treatment with ranibizumab or aflibercept; or d)    vitreomacular traction for access to initial treatment with ocriplasmin; under the pharmaceutical benefits scheme are fulfilled. Maximum of one service in a 12 month period	40.00
11220	Optical coherence tomography for the assessment of the need for treatment following provision of pharmaceutical benefits scheme‑subsidised ocriplasmin. Maximum of one service per eye per lifetime.	40.00

Schedule 3 – amendments

Health Insurance (Optical Coherence Tomography) Determination 2016

1     Schedule 1

Repeal the Schedule.