Health Insurance (1998-99 Pathology Services Table) Amendment Regulations 1999 (No. 1) 1999 No. 19
EXPLANATORY STATEMENT
STATUTORY RULES 1999 No. 19
Issued by the Authority of the Minister for Health and Aged Care
Health Insurance Act 1973
Health Insurance (1998-99 Pathology Services Table) Amendment Regulations 1999 (No. 1)
Section 133 of the Act provides that the Governor-General may make regulations prescribing matters for the purposes of the Act.
Section 9 of the Act provides that medicare benefits shall be calculated by reference to the fees for medical services (including pathology services) set out in the table.
Section 4A of the Act provides that a table of pathology services may be prescribed. The Health Insurance (199899 Pathology Services Table) Regulations 1998, which commence on 1 November 1998, prescribed such a table.
The 1998-99 Pathology Services Table of the Medicare Benefits Schedule incorporated extensive changes as part of its annual renewal. As a result of practical feedback on the application of these changes, a number of further revisions have been made, including changes to the HIV viral load items following a review of more recent evidence in this area.
The changes to the 1998-99 Pathology Services Table have been developed with the cooperation and support of the two peak pathology professional bodies, the Royal College of Pathologists of Australasia and the Australian Association of Pathology Practices, through the Pathology Services Table Committee and the Pathology Consultative Committee.
The changes have no major financial implications and are included within the expenditure targets for 1998199 as set under the current Pathology Agreement.
Details of the Regulations are set out in the Attachment.
The Regulations commence on 1 March 1999.
ATTACHMENT
Regulation 1 cites the regulations as the Health Insurance (1998-99 Pathology Services Table) Amendment Regulations 1999. (No. 1)
Regulation 2 prescribes a commencement date of 1 March 1999.
Regulation 3 prescribes the amendments to the Health Insurance (1998-99 Pathology Services Table) Regulations 1998.
The changes under Regulation 3, Schedule 1 are:
Item 1 amended an existing rule for HIV viral RNA load testing by increasing the test limit claim from 6 to 7 in a 12 month period.
Item 2 inserted a new rule to apply to the two folate items (items 66599 and 66602) which specifies that no more than a maximum of 3 episodes can be claimed in a 12 month period for both items and defines the claiming circumstances should both items occur in the same patient episode.
Item 3 amended two HIV viral RNA load items (items 693 78 and 693 8 1), the two folate items (items 66599 and 66602) and a microbiology item (item 69375).
Item 4 inserted a new item for the measurement of HIV viral RNA load in cerebrospinal fluid for HIV sero-positive patients with nervous system involvement (item 69382).
Overview
The Health Insurance (1998-99 Pathology Services Table) Amendment Regulations 1999 (No. 1) were enacted to address certain issues and gaps identified in the application of the 1998-99 Pathology Services Table of the Medicare Benefits Schedule. The regulations were introduced under the authority of the Minister for Health and Aged Care and were made pursuant to Section 133 of the Health Insurance Act 1973. The primary policy objective of these regulations is to ensure the accuracy and appropriateness of medical services fees, particularly in the context of pathology services, by implementing necessary adjustments based on practical feedback and recent evidence reviews. These amendments are intended to have no major financial implications and are aligned with the expenditure targets set under the current Pathology Agreement.
The regulations were developed in collaboration with key professional bodies in the pathology sector, namely the Royal College of Pathologists of Australasia and the Australian Association of Pathology Practices, through the Pathology Services Table Committee and the Pathology Consultative Committee. The changes introduced by these regulations, which came into effect on 1 March 1999, include modifications to the HIV viral load items and the folate items, as well as the addition of a new item for the measurement of HIV viral RNA load in cerebrospinal fluid for HIV sero-positive patients with nervous system involvement.
Scope and Application
The Health Insurance (1998-99 Pathology Services Table) Amendment Regulations 1999 (No. 1) applies to the Medicare benefits prescribed under the Health Insurance Act 1973, specifically for pathology services as defined in the Medicare Benefits Schedule. The amendments target entities such as medical practitioners, pathology laboratories, and patients eligible for Medicare benefits. These regulations aim to revise the fees and claiming limits for specific pathology services, including HIV viral load testing and folate testing, to align with recent clinical evidence and practical feedback. The Regulations, which commence on 1 March 1999, are made under the authority of the Minister for Health and Aged Care and are designed to ensure that the benefits remain fair and accurately reflect the current standards of medical practice. The amendments are integral to maintaining the integrity of the Medicare system and do not extend beyond the specific services outlined in the Regulations.
Key Provisions
The Health Insurance (1998-99 Pathology Services Table) Amendment Regulations 1999 (No. 1) (referred to as the "Regulations") primarily focus on amending the 1998-99 Pathology Services Table under the Health Insurance Act 1973 (the "Act"). Section 4A of the Act allows for the prescription of a table of pathology services, and the Regulations amend the existing Health Insurance (1998-99 Pathology Services Table) Regulations 1998 to reflect practical feedback and updated evidence, particularly in relation to HIV viral load testing and folate testing.
The Regulations impose specific obligations on the parties involved, primarily concerning the updated rules for claiming certain pathology services under Medicare. For instance, Regulation 3, Schedule 1, Item 1 increases the test limit claim for HIV viral RNA load testing from 6 to 7 in a 12-month period. This means that pathology providers can now claim up to 7 tests per patient annually, instead of the previous limit of 6. Furthermore, Item 2 specifies that no more than a maximum of 3 episodes can be claimed in a 12-month period for two folate items (items 66599 and 66602) and defines the claiming circumstances should both items occur in the same patient episode. These changes aim to ensure that the services provided are accurately reflected and appropriately reimbursed under Medicare.
In terms of compliance, the Regulations require that all pathology providers adhere to the updated rules as specified in the amended Table. Failure to comply with these amendments could result in incorrect billing and potential financial discrepancies. The Regulations do not explicitly state any specific penalties for non-compliance, but any breaches of the Medicare regulations could potentially lead to civil or criminal consequences under the Act. The Act generally provides for penalties including fines and imprisonment for wilful or negligent breaches.
The Regulations also introduce new items and amend existing ones, as outlined in Schedule 1. For example, Item 4 inserts a new item for the measurement of HIV viral RNA load in cerebrospinal fluid for HIV sero-positive patients with nervous system involvement (item 69382). Such amendments ensure that the services provided are accurately represented and appropriately reimbursed under Medicare, reflecting the latest clinical evidence and practical feedback. The Regulations, by updating the Table, ensure that the services provided and the fees for those services are consistent with the current standards and requirements of the Medicare system.