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

Legislation au C2004L06639 Not in force Legislative Instrument

Legislation content

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 1 Preliminary

 1 Name of Determination 

 2 Commencement 

 3 Interpretation 

Part 2 Allied health services

 4 Allied health services 

 5 Application and interpretation 

Part 3 Dental health services

 6 Dental health services 

 7 Application and interpretation 

Schedule 1 Allied health services 

Schedule 2 Dental health services 

 

Part 1 Preliminary

 

1 Name of Determination

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

2 Commencement

  This Determination commences on 1 July 2004.

3 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

 

4 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.

5 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

 

6 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.

7 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

 

Overview

The Health Insurance (Allied Health and Dental Services) Determination HS/06/2004, enacted by Tony Abbott, the Minister for Health and Ageing, under subsection 3C(1) of the Health Insurance Act 1973, was introduced to address the gap in coverage for allied health and dental services under the Medicare system. This legislation aimed to ensure that allied health and dental services are treated as both professional and medical services, aligning them with the existing framework of health services covered by Medicare. By doing so, it aimed to provide a more comprehensive approach to health care, ensuring that patients have access to a broader range of health services under their insurance. The policy objective was to integrate allied health and dental services into the Medicare Benefits Schedule, thereby improving the accessibility and affordability of these essential health services for the Australian public.

Scope and Application

The Health Insurance (Allied Health and Dental Services) Determination HS/06/2004 applies to allied health services and dental health services provided within Australia. Specifically, it governs the treatment of these services under the Health Insurance Act 1973, ensuring they are recognised as both professional and medical services. The Determination stipulates that for these services to be eligible for benefits under the Act, they must be provided by qualified professionals whose names are registered in relevant lists maintained by the Commission. These services are applicable to individuals who are managing chronic and complex conditions under an Enhanced Primary Care Multidisciplinary Care Plan, and they must be recommended by a medical practitioner. The services themselves must be individually provided in person, last at least 20 minutes, and include a written report from the service provider to the referring medical practitioner. Additionally, the services can be claimed under the Medicare benefit rather than private health insurance, subject to a maximum of 5 allied health services and 3 dental services per 12-month period. The Determination outlines specific fees for each service item and applies to all states and territories in Australia, with the Australian Capital Territory being treated as part of New South Wales for these purposes.

Key Provisions

The Health Insurance (Allied Health and Dental Services) Determination HS/06/2004 establishes specific provisions for allied health and dental services under the Health Insurance Act 1973. Section 4 of Part 2 stipulates that allied health services are to be treated as both professional and medical services, with corresponding entries in the general medical services table specifying fees for each state. Section 6 of Part 3 mandates similar treatment for dental health services, with entries in the general medical services table detailing fees. These provisions ensure that allied health and dental services are recognised and reimbursed appropriately under the Act. The Act imposes several obligations on the parties it governs. For allied health services, eligible allied health professionals must be registered with the relevant authority and their names must appear in the Commission's register of qualified professionals. They must also adhere to specific conditions, such as providing services to patients with chronic and complex conditions managed by a medical practitioner under an Enhanced Primary Care (EPC) multidisciplinary care plan. Additionally, services must be referred by a medical practitioner using a referral form issued by the Commission, and must be provided individually and in person for at least 20 minutes. Similar requirements apply to dental health services, where eligible dental practitioners or specialists must be registered, and services must be part of an EPC multidisciplinary care plan, referred by a medical practitioner, and provided individually and in person. Breach of the provisions outlined in this Determination can result in civil and criminal consequences. The Act does not specify maximum penalties within the text provided, but typically, breaches of health-related legislation can lead to fines and, in severe cases, criminal charges. Non-compliance with the requirements for service provision, registration, and referral can potentially result in penalties under the Health Insurance Act 1973 or other related legislation, including fines and legal action. Additionally, failure to adhere to the specified conditions for service reimbursement could result in the denial of Medicare benefits or private health insurance rebates for the services provided.

Legal classification tags

Area of Law
Health Law
Instrument
Legislative Instrument
Concepts
Definitions & Interpretation
Reporting & Disclosure Obligations
Regulatory Standards

Interactions

Authorises

All Versions

Sourced from the Federal Register of Legislation at 26 August 2026. For the latest information on Australian Government law please go to https://www.legislation.gov.au.