EXPLANATORY STATEMENT

Issued by the Authority of the Minister for Health and Ageing

Health Insurance Act 1973

Health Insurance (Allied Health and Dental Services) Determination 2005

Subsection 3C(1) of the Health Insurance Act 1973 (the Act) provides that the Minister may, by writing, determine that a health service not listed in the general medical services table shall, in specified circumstances and for specified statutory provisions, be treated as if it were so listed.

A determination made under subsection 3C(1) is a legislative instrument within the meaning of the Legislative Instruments Act 2003.

Subsection 3C(8) provides that the health services that may be subject to a determination made under subsection 3C(1) include dental services and any other prescribed service that relates to health.  Regulation 3A of the Health Insurance Regulations 1975 prescribes 13 classes of allied health services as “health services” for the purposes of section 3C of the Act. 

The purpose of this Determination is to specify that certain allied health and dental services that can be provided to people with chronic conditions and complex care needs are to be treated as if they were listed in the general medical services table. 

The Determination enables the payment of Medicare benefits for the specified allied health and dental services and gives effect to changes necessitated by the introduction of additional care planning items (chronic disease management items) to the general medical services table.  These changes provide that Medicare benefits may be payable for certain allied health and dental services 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 plan (defined to comprehend Enhanced Primary Care (EPC) multidisciplinary care plans and the combination of both a GP management plan and team care arrangements).

The fees and specified circumstances applying to each item are set out in this Determination. 

Details of this Determination are set out in the Attachment. 

The Determination commences on 1 July 2005.

Consultation

These changes are consequent upon the introduction of new chronic disease management items with effect from 1 July 2005.  These chronic disease management items have been developed in consultation with representatives of General Practice organisations.  Consultation has occurred both through a specific advisory group, established to advise on the detailed design and implementation  of changes to the Practice Incentives Program and EPC Medicare items arising from recommendations of the Red Tape Taskforce, and through the Medicare Benefits Consultative Committee, which formally considered the new Medicare items.  Representatives of allied health and dental services professional organisations have been briefed on the consequential changes to link access to certain allied health and dental services to the new items.

ATTACHMENT

DETAILS OF THE HEALTH INSURANCE (ALLIED HEALTH AND DENTAL SERVICES) DETERMINATION 2005

Section 1 provides for the Determination to be referred to as the Health Insurance (Allied Health and Dental Services) Determination 2005.

Section 2 provides for the Determination to commence on 1 July 2005.

Section 3 provides for the revocation of the Health Insurance (Allied Health and Dental Services) Determination HS/06/2004.

Section 4 provides descriptions of the terms used in the Determination.

Section 5 provides that an allied health service described in Schedule 1 is to be treated as if it were both a “professional service” and a “medical service” for the purposes of relevant provisions of the Act, the National Health Act 1953, and Regulations made under those Acts, and as if there were an item in the general medical services table that related to the service and specified a fee relating to the service.

Section 6 provides that a dental health service described in Schedule 2 is to be treated as if it were both a “professional service” and a “medical service” for the purposes of relevant provisions of the Act, the National Health Act 1953, and Regulations made under those Acts, and as if there were an item in the general medical services table that related to the service and specified a fee relating to the service.

Schedule 1 – Allied Health Services

Part 1 provides descriptions of terms used in Schedule 1.

Part 2 provides for the continuance of 12 items for allied health services provided by eligible persons who are health professionals of the following types.

Item 10950 – Aboriginal health worker

Item 10951 – Diabetes educator

Item 10952 – Audiologist

Item 10954 – Dietitian

Item 10956 – Mental health worker

Item 10958 – Occupational therapist

Item 10960 – Physiotherapist

Item 10962 – Chiropodist or podiatrist

Item 10964 – Chiropractor

Item 10966 – Osteopath

Item 10968 – Psychologist

Item 10970 – Speech pathologist

Each of these items operates in an equivalent manner.  Each of the items in this Schedule applies when the following specified circumstances are satisfied.

• 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 plan. 
• An EPC plan, in relation to a patient, means: 

(a)  an enhanced primary care multidisciplinary care plan for the patient, comprising:

(i) a multidisciplinary community care plan for the patient, to which item 720 of the general medical services table applies; or

(ii) a multidisciplinary discharge care plan for the patient, to which item 722 of the general medical services table applies; or

(iii) a multidisciplinary care plan for the patient, to which item 730 or item 731 of the general medical services table applies; or

(b)   a care plan for the patient comprising:

(i)  a GP management plan to which item 721 of the general medical services table applies; and

(ii)  team care arrangements to which item 723 of the general medical services table applies.

• The service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition.

• The person is referred to the relevant eligible allied health professional by the medical practitioner using a referral form issued by the Health Insurance Commission.

• The person is not an admitted patient of a hospital or day-hospital facility.

• The service is provided to the person individually and in person.

• The service is of at least 20 minutes duration.

• After the service, the relevant allied health professional gives a written report to the referring medical practitioner.

• If a private health insurance benefit is payable in relation to the service, the person who incurred the medical expenses in relation to the service has elected to claim the Medicare benefit and not the private health insurance benefit for the service.

A Medicare benefit will be paid up to a maximum of five allied health services per person in a 12 month period.  This requirement refers to five services covered by any of the items 10950 to 10970 in Schedule 1, commencing from the date of the first service.

Schedule 2 – Dental Health Services

Part 1 provides a description of terms used in Schedule 2.

Part 2 provides for the continuance of three items for certain services provided by an eligible person who is a dental practitioner or a dental specialist. 

Item 10975 applies to a dental assessment provided to a person by an eligible dental practitioner on referral by a medical practitioner using a referral form issued by the Health Insurance Commission.  After the assessment, the dental practitioner must provide a written report to the referring medical practitioner.

Item 10976 applies to dental treatment provided to a person by an eligible dental practitioner on referral by a medical practitioner using a referral form issued by the Health Insurance Commission, where the service is associated with a service that the person has previously received covered by item 10975.

Item 10977 applies to a dental service provided to a person by another eligible dental practitioner or eligible dental specialist on referral by a dental practitioner, where the service is associated with a service that the person has previously received covered by item 10975.  After the service, the dental practitioner or dental specialist must provide a written report to the referring dental practitioner and the referring medical practitioner.

In addition, items 10975, 10976 and 10977 will only apply if the following specified circumstances are satisfied.

• 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 plan.
• An EPC plan, in relation to a patient, means: 

(a)  an enhanced primary care multidisciplinary care plan for the patient, comprising:

(i) a multidisciplinary community care plan for the patient, to which item 720 of the general medical services table applies; or

(ii) a multidisciplinary discharge care plan for the patient, to which item 722 of the general medical services table applies; or

(iii) a multidisciplinary care plan for the patient, to which item 730 or item 731 of the general medical services table applies; or

(b)  a care plan for the patient comprising:

(i)  a GP management plan to which item 721 of the general medical services table applies; and

(ii)  team care arrangements to which item 723 of the general medical services table applies.

• The service is recommended in the person’s EPC plan as part of the management of the person’s chronic and complex condition.

• The person is not an admitted patient of a hospital or day-hospital facility.

• If a private health insurance benefit is payable in relation to the service, the person who incurred the medical expenses in relation to the service has elected to claim the Medicare benefit and not the private health insurance benefit for the service.

A Medicare benefit will be paid up to a maximum of three dental services per person in a 12 month period.  This requirement refers to three services covered by any of the items 10975, 10976 or 10977 of Schedule 2, commencing from the date of the first service.