National Health (Entitlement to Pharmaceutical Benefits — Special Evidentiary Categories) Determination 2001 (Cth)
National Health (Entitlement to Pharmaceutical Benefits — Special Evidentiary Categories) Determination 2001
I, Jennifer Marette Badham, Acting Assistant Secretary, Department of Health and Aged Care, delegate of the Minister for Health and Aged Care, make this Determination under subsection 86E (1) of the National Health Act 1953.
Dated 3 December 2001
J M Badham (signed)
Acting Assistant Secretary
BMMS Implementation Taskforce
Department of Health and Ageing
Contents
Page
Part 1 Preliminary
1.1 Name of Determination 2
1.2 Commencement 2
1.3 Definitions 2
1.4 Purpose of Determination 3
Part 2 Classes of persons
2.1 Determination of classes 5
2.2 Persons requiring drugs or medicinal preparations in an emergency 5
2.3 Foreign persons covered by reciprocal health care agreements 6
2.4 Persons without medicare number who a prescriber considers are entitled to pharmaceutical benefit 7
2.5 Persons without medicare number who an approved supplier considers are entitled to pharmaceutical benefit 8
2.6 Persons requiring drugs or medicinal preparations as a matter of clinical urgency 9
2.7 Persons for whom an inapplicable medicare number is shown on a seemingly valid medicare card 10
Part 3 Special numbers
3.1 Applicable special numbers 12
3.2 Procedure for allocating applicable special number 12
Part 1 Preliminary
1.1 Name of Determination
This Determination is the National Health (Entitlement to Pharmaceutical Benefits — Special Evidentiary Categories) Determination 2001.
1.2 Commencement
This Determination commences on gazettal.
1.3 Definitions
In this Determination:
Act means the National Health Act 1953.
agent, of a person to whom a prescription for the supply of a pharmaceutical benefit relates, means a person acting on behalf of that person.
approved supplier includes an employee of an approved supplier.
Australian resident has the meaning given by subsection 3 (1) of the Health Insurance Act 1973.
eligible overseas representative has the meaning given by subsection 3 (1) of the Health Insurance Act 1973.
eligible person has the meaning given by subsection 3 (1) of the Health Insurance Act 1973.
person to whom the prescription for the supply of a pharmaceutical benefit relates means the person named in the prescription, or in a communication in accordance with paragraph 89 (a) of the Act, by the prescriber as the person to whom the pharmaceutical benefit is to be administered.
prescriber, of a prescription for the supply of a pharmaceutical benefit to a person, means the medical practitioner or participating dental practitioner who has written or communicated the prescription.
reciprocal health care agreement means an agreement made under section 7 of the Health Insurance Act 1973.
subsidised non-medicare number medical service means a medical service or dental service provided to an eligible person within the meaning of the Health Insurance Act 1973 that is subsidised directly or indirectly by a Commonwealth, State or local government or a charitable or religious organisation.
unsubsidised non-medicare number medical service means a medical service or dental service provided to an eligible person within the meaning of the Health Insurance Act 1973 that:
(a) is not subsidised directly or indirectly by a Commonwealth, State or local government or a charitable or religious organisation; and
(b) is provided:
(i) free of charge; or
(ii) if not free of charge:
(A) on the basis that it does not relate to membership of a life insurance scheme, superannuation scheme, provident account scheme or friendly society; or
(B) on the basis that the medical or dental expenses are not incurred by the person’s employer and are not related to any industrial undertaking.
Note The following terms are defined in subsection 84 (1) of the Act:
· approved supplier
· expiry date
· medicare card
· medicare number
· participating dental practitioner
· pharmaceutical benefit
· special number.
1.4 Purpose of Determination
This Determination:
(a) determines the classes of persons in respect of whom an entitlement to pharmaceutical benefits can be evidenced otherwise than by provision of a medicare number; and
(b) sets out, where appropriate, the particular matters in respect of which an approved supplier must be satisfied before being satisfied that a person is included within a particular class identified in this Determination; and
(c) sets out, where appropriate, the procedure to be followed by the approved supplier in establishing the matters mentioned in paragraph (b); and
(d) provides in Part 3, in respect of each class of persons identified in Part 2, the procedure for allocating a particular combination of numbers, or letters and numbers, that is to be the special number applicable to a person included within that class as a member of that class.
Part 2 Classes of persons
2.1 Determination of classes
(1) Each of the following classes of persons is determined to be a class of persons in respect of whom an entitlement to pharmaceutical benefits can be evidenced otherwise than by provision of a medicare number:
(a) persons requiring drugs or medicinal preparations in an emergency;
(b) foreign persons covered by reciprocal health care agreements;
(c) persons without medicare number who a prescriber considers are entitled to pharmaceutical benefit;
(d) persons without medicare number who an approved supplier considers are entitled to pharmaceutical benefit;
(e) persons requiring drugs or medicinal preparations as a matter of clinical urgency;
(f) persons for whom an inapplicable medicare number is shown on a seemingly valid medicare card.
(2) A person is included within a class of persons mentioned in subsection (1) if the requirements of the relevant section in this Part are satisfied in relation to the person.
2.2 Persons requiring drugs or medicinal preparations in an emergency
A person is included within the class of persons mentioned in paragraph 2.1 (1) (a) (persons requiring drugs or medicinal preparations in an emergency) if the following requirements are satisfied in relation to the person:
(a) the person is a person to whom a prescription for the supply of a pharmaceutical benefit relates;
(b) at the time of the supply of the pharmaceutical benefit by an approved supplier:
(i) the approved supplier has no reason to believe that the person is not, or is not entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973; and
(ii) the person or another person is likely to suffer imminent death, serious ill health or serious injury (the emergency);
(c) in order to prevent that emergency, the pharmaceutical benefit must be supplied to the person or the person’s agent:
(i) immediately; or
(ii) within a period that is too short to enable questions relating to eligibility or identity to be asked and answered, or for other action to be taken to establish the person’s eligibility or identity;
(d) at the time of the making by the approved supplier of a claim for payment by the Commonwealth in relation to the supply of the pharmaceutical benefit, the approved supplier confirms that:
(i) a medicare number applicable to the person has not been provided to the approved supplier; and
(ii) a medicare number is not retained in the approved supplier’s records in accordance with section 86D of the Act as a number applicable to the person.
2.3 Foreign persons covered by reciprocal health care agreements
A person is included within the class of persons mentioned in paragraph 2.1 (1) (b) (foreign persons covered by reciprocal health care agreements) if the following requirements are satisfied in relation to the person:
(a) the person is a person to whom a prescription for the supply of a pharmaceutical benefit relates;
(b) at the time of the supply of the pharmaceutical benefit by an approved supplier, the approved supplier has no reason to believe that the person is not, or is not entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973;
(c) at the time of the supply of the pharmaceutical benefit, the person, or the person’s agent, has been requested by the approved supplier to provide a medicare number as a number applicable to the person;
(d) at the time of the supply of the pharmaceutical benefit, the person, or the person’s agent, informs the approved supplier that:
(i) the person has not been allocated a medicare number applicable to the person; and
(ii) the person has not been advised by the Health Insurance Commission, orally or in writing, that a medicare number has been, or will be, allocated to the person; and
(iii) the person is not an eligible person within the meaning of the Health Insurance Act 1973 by reason of being an Australian resident or an eligible overseas representative; and
(iv) the person is entitled to receive pharmaceutical benefits only by reason of being entitled to be treated as an eligible person under a reciprocal health care agreement;
(e) at the time of the supply of the pharmaceutical benefit, the approved supplier has no reason to believe that the person has a medicare number applicable to the person;
(f) before the making by the approved supplier of a claim for payment by the Commonwealth in relation to the supply of the pharmaceutical benefit:
(i) the person, or the person’s agent, provides to the approved supplier a passport covering the person; and
(ii) after examining the passport, the approved supplier is satisfied that:
(A) the passport was issued by a country with which there is in force a reciprocal health care agreement; and
(B) the date of expiry of the passport had not elapsed at the time of the supply of the pharmaceutical benefit;
(g) at the time of the supply of the pharmaceutical benefit, the approved supplier has no reason to believe that the person does not have a valid visa;
(h) at the time of the making by the approved supplier of a claim for payment by the Commonwealth in relation to the supply of the pharmaceutical benefit, the approved supplier confirms that:
(i) a medicare number applicable to the person has not been provided to the approved supplier; and
(ii) a medicare number is not retained in the approved supplier’s records in accordance with section 86D of the Act as a number applicable to the person.
2.4 Persons without medicare number who a prescriber considers are entitled to pharmaceutical benefit
A person is included within the class of persons mentioned in paragraph 2.1 (1) (c) (persons without medicare number who a prescriber considers are entitled to pharmaceutical benefit) if the following requirements are satisfied in relation to the person:
(a) the person is a person to whom a prescription for the supply of a pharmaceutical benefit relates;
(b) at the time of the supply of the pharmaceutical benefit by an approved supplier, the approved supplier has no reason to believe that the person is not, or is not entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973;
(c) the prescriber of the prescription provided the prescription as the result of providing to the person a service that the prescriber believed was a subsidised non-medicare number medical service or an unsubsidised non-medicare number medical service;
(d) at the time of providing the prescription, the prescriber has no reason to believe that the person is not, or is not entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973;
(e) either:
(i) the person was not required to provide, and did not provide, to the prescriber a medicare number applicable to the person; or
(ii) at the time of providing the prescription, the prescriber did not have a record of, or did not have access to, a medicare number applicable to the person;
(f) the prescriber has not included on the prescription a medicare number as a number applicable to the person;
(g) the prescriber has included on the prescription the words ‘non‑medicare-number service’, ‘nonMNS’ or ‘non-MNS’, or the special number applicable to the person under Part 3;
(h) at the time of the supply of the pharmaceutical benefit, the approved supplier has no reason to believe that the person, or the person’s agent, has in his or her possession:
(i) a medicare card showing a medicare number applicable to the person; or
(ii) a document issued by the Health Insurance Commission showing a medicare number applicable to the person;
(i) at the time of the making by the approved supplier of a claim for payment by the Commonwealth in relation to the supply of the pharmaceutical benefit, the approved supplier confirms that:
(i) a medicare number applicable to the person has not been provided to the approved supplier; and
(ii) a medicare number is not retained in the approved supplier’s records in accordance with section 86D of the Act as a number applicable to the person.
2.5 Persons without medicare number who an approved supplier considers are entitled to pharmaceutical benefit
A person is included within the class of persons mentioned in paragraph 2.1 (1) (d) (persons without medicare number who an approved supplier considers are entitled to pharmaceutical benefit) if the following requirements are satisfied in relation to the person:
(a) the person is a person to whom a prescription for the supply of a pharmaceutical benefit relates;
(b) at the time of the supply of the pharmaceutical benefit by an approved supplier, the approved supplier has no reason to believe that the person, or the person’s agent, has in his or her possession:
(i) a medicare card showing a medicare number applicable to the person; or
(ii) a document issued by the Health Insurance Commission showing a medicare number applicable to the person;
(c) at the time of the supply of the pharmaceutical benefit, the approved supplier is satisfied that the person is, or is entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973, but is not a person who is covered by a reciprocal health care agreement;
(d) at the time of the supply of the pharmaceutical benefit, the approved supplier is satisfied that:
(i) the pharmaceutical benefit was prescribed as the result of a subsidised non-medicare number medical service; or
(ii) for other reasons, it is not reasonable for the person to provide a medicare number applicable to the person;
(e) at the time of the making by the approved supplier of a claim for payment by the Commonwealth in relation to the supply of the pharmaceutical benefit, the approved supplier confirms that:
(i) a medicare number applicable to the person has not been provided to the approved supplier; and
(ii) a medicare number is not retained in the approved supplier’s records in accordance with section 86D of the Act as a number applicable to the person.
2.6 Persons requiring drugs or medicinal preparations as a matter of clinical urgency
A person is included within the class of persons mentioned in paragraph 2.1 (1) (e) (persons requiring drugs or medicinal preparations as a matter of clinical urgency) if the following requirements are satisfied in relation to the person:
(a) the person is a person to whom a prescription for the supply of a pharmaceutical benefit relates;
(b) at the time of the supply of the pharmaceutical benefit by an approved supplier, the approved supplier has no reason to believe that the person is not, or is not entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973;
(c) at the time of the supply of the pharmaceutical benefit, the person, or the person’s agent, has been requested by the approved supplier to provide a medicare number as a number applicable to the person;
(d) at the time of the supply of the pharmaceutical benefit, the approved supplier, being satisfied in relation to the matter mentioned in paragraph (c), has reason to believe that, in his or her professional opinion, the immediate supply of the medicine is necessary:
(i) to initiate urgent treatment; or
(ii) to continue without interruption an existing necessary regime of treatment;
(e) at the time of the making by the approved supplier of a claim for payment by the Commonwealth in relation to the supply of the pharmaceutical benefit, the approved supplier confirms that:
(i) a medicare number applicable to the person has not been provided to the approved supplier; and
(ii) a medicare number is not retained in the approved supplier’s records in accordance with section 86D of the Act as a number applicable to the person.
2.7 Persons for whom an inapplicable medicare number is shown on a seemingly valid medicare card
A person is included within the class of persons mentioned in paragraph 2.1 (1) (f) (persons for whom an inapplicable medicare number is shown on a seemingly valid medicare card) if the following requirements are satisfied in relation to the person:
(a) the person is a person to whom a prescription for the supply of a pharmaceutical benefit relates;
(b) at the time of the supply of the pharmaceutical benefit by an approved supplier, the approved supplier has no reason to believe that the person is not, or is not entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973;
(c) the approved supplier has made a claim for payment by the Commonwealth in relation to the supply of the pharmaceutical benefit (the previous claim);
(d) the previous claim included a medicare number as a number applicable to the person;
(e) in processing the previous claim, the Health Insurance Commission found that:
(i) the medicare number did not correspond with a medicare number that was held in the records of the Health Insurance Commission as a number applicable to the person; or
(ii) at the time of the supply of the pharmaceutical benefit, the person was not, or was not entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973;
(f) at least 60 days before a new claim for the supply of the pharmaceutical benefit, the Health Insurance Commission notified the approved supplier that:
(i) the medicare number included in the previous claim did not correspond with a medicare number that was held in the records of the Health Insurance Commission as a number applicable to the person; or
(ii) the person was not, or was not entitled to be treated as, an eligible person within the meaning of the Health Insurance Act 1973;
(g) the approved supplier is unable to obtain from the person, in relation to a new claim for the supply of the pharmaceutical benefit, another medicare number applicable to the person;
(h) the approved supplier:
(i) has a true and readable photocopy or photograph of a medicare card showing the medicare number included in the previous claim; or
(ii) has completed and signed a statement in the form approved by the Department for the purposes of this provision;
(i) the approved supplier:
(i) makes a new claim for payment by the Commonwealth in relation to the supply of the pharmaceutical benefit; and
(ii) attaches the photocopy or photograph of the medicare card, or the signed statement, to the prescription for the supply.
Part 3 Special numbers
3.1 Applicable special numbers
The special number applicable to a person included within a class of persons determined under Part 2 is:
(a) for a person within the class of persons mentioned in paragraph 2.1 (1) (a) (persons requiring drugs or medicinal preparations in an emergency) — 2543 77541 1 1; and
(b) for a person within the class of persons mentioned in paragraph 2.1 (1) (b) (foreign persons covered by reciprocal health care agreements) — 2543 77596 1 1; and
(c) for a person within the class of persons mentioned in paragraph 2.1 (1) (c) (persons without medicare number who a prescriber considers are entitled to pharmaceutical benefit) — 2543 77666 1 1; and
(d) for a person within the class of persons mentioned in paragraph 2.1 (1) (d) (persons without medicare number who an approved supplier considers are entitled to pharmaceutical benefit) — 2543 77684 1 1; and
(e) for a person within the class of persons mentioned in paragraph 2.1 (1) (e) (persons requiring drugs or medicinal preparations as a matter of clinical urgency) — 2543 75299 1 1; and
(f) for a person within the class of persons mentioned in paragraph 2.1 (1) (f) (persons for whom an inapplicable medicare number is shown on a seemingly valid medicare card) — 2543 77833 1 1.
3.2 Procedure for allocating applicable special number
The procedure for allocating the special number applicable to a person included within a class of persons determined under Part 2 is as follows:
Step 1 Consult a table, list or computer file of the special numbers specified in section 3.1.
Step 2 Select from that table, list or computer file the special number applicable to the class of persons that includes the person.
Step 3 Allocate that number as the special number applicable to the person.
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