Health Insurance (Amendment) Determination HS/04/2005

Administered by Department of Health, Disability and Ageing

Legislation au F2005L03309 Not in force Legislative Instrument

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EXPLANATORY STATEMENT

Issued by the Authority of the Minister for Health and Ageing

Health Insurance Act 1973

Health Insurance (Amendment) Determination HS/04/2005

Subsection 3C(1) of the Health Insurance Act 1973 (“the Act”) allows the Minister to determine in writing that a specified health service (which is not listed in the Medicare Benefits Schedule) shall, in specified circumstances and for specified statutory provisions, be treated as if it were so listed.

The effect of subsection 3C(4) of the Act is that a determination made under subsection 3C(1) of the Act is a legislative instrument for the purposes of the Legislative Instruments Act 2003.

Section 3C determinations have previously been made for the following health services:

HS/4/1999 – bone densitometry testing;

HS/6/1999 – grafting of infrarenal abdominal aortic aneurysm;

HS/03/2001 – treatment by hyperbaric oxygen therapy of soft tissue radionecrosis or chronic or recurring wounds where hypoxia can be demonstrated;

HS/01/2002 – treatment of sacral nerve stimulation services;

HS/09/2002 – photodynamic therapy (Patients who commenced therapy after 1 June 2002);

HS/10/2002 – photodynamic therapy (Patients who commenced therapy before 1 June 2002);

HS/01/2005 – deep brain stimulation for Parkinson’s disease;

Allied health and dental services, dated 27 June 2005.

Health Insurance (Amendment) Determination HS/04/2005 (“the Determination”) amends each of the above determinations to provide for an increase in the fees for the services covered in these determinations. This fee increase is in line with the general fee increase of 2.0 percent that is being applied to the Medicare Benefits Schedule (MBS) from 1 November 2005.

The Determination also amends:

HS/04/2003 (botulinum toxin) to change the date of cessation from 30 April 2006 to the beginning of 1 November 2005, as the items it covers will be listed in the MBS from 1 November 2005.

The above determination was made to allow benefits to be paid until 30 April 2006, for botulinum toxin injection for certain indications which were in long-standing clinical usage but had not been approved by the Therapeutic Goods Administration (TGA). This was done to allow time for the drug sponsors to obtain these TGA approvals. All the indications covered under the determination now have TGA approval. Therefore the items will be transferred to the MBS for coverage from 1 November 2005, and accordingly the determination will cease from the beginning of 1 November 2005.

HS/01/2005 (deep brain stimulation for Parkinson’s Disease) to:

- change the date of cessation from 30 April 2006 to the beginning of 1 November 2006 to allow sufficient time for a review by the Medical Services Advisory Committee (MSAC) to be completed;

- add St Vincents Private Hospital, Victoria, to the list of ‘relevant centres’ in which deep brain stimulation (DBS) services may be performed, and

- remove the restriction on item 40862 that the service must be performed in one of the ‘relevant centres’ listed in the above determination.

The above determination was introduced (originally under HS/07/2001) following a review by the MSAC, which recommended interim funding for DBS services conducted in ‘relevant centres’, until further data was available and had been reviewed. MSAC commenced this further review this year, but because of delays in the supply of data from Australian centres will not be able to complete the review until early-to-mid 2006. Therefore the determination is being extended from 30 April 2006 to the beginning of 1 November 2006, by which time it is expected the outcome of the MSAC review will be available.

The effect of the second amendment is to add St Vincents Private Hospital, Victoria, to the list of ‘relevant centres’ in which DBS can be conducted. It was not one of the original centres listed, but now has the equipment and appropriate arrangements in place to perform the services.

The effect of the third amendment (removal of the restriction on item 40862 to ‘relevant centres’) is to allow this service (programming) to be claimed if done elsewhere eg doctor’s rooms. The profession and manufacturer have provided evidence that this restriction is unnecessary, as 40862 is a routine outpatient service, unlike the other DBS services, which are surgical procedures.

HS/09/2002 (photodynamic therapy) to

- increase the limit on the number of photodynamic therapy treatments allowed under this determination from 10 to 15; and

- include two new items (42991 and 43000) to cover the 11th to 15th treatments.

The above determination (originally made under HS/05/2002) was introduced following a review by MSAC which recommended interim funding for photodynamic therapy services under specified circumstances. This included a limit on the number of treatments allowed to 10 services per patient. The effect of the above amendments is to increase the limit to 15 for patients who require more than 10 treatments, and introduce two new items to reflect this. This follows representations from the profession in support of this amendment, to cover the small number of patients needing additional treatments.

Details of the Determination (HS/04/2005) are set out in the Attachment.

The Determination commences on 1 November 2005.

ATTACHMENT

NOTES ON CLAUSES

Clause 1 provides that the name of the Determination is the Health Insurance (Amendment) Determination HS/04/2005.

Clause 2 provides that the Determination commences on 1 November 2005.

Clause 3 provides for the amendment of various section 3C Determinations, as set out in the Schedules to the Determination.

Schedule 1

Item 1 of Schedule 1 amends Health Insurance Determination HS/4/1999 to increase the fee for the service in that determination by 2 per cent.

Schedule 2

Items 1 and 2 of Schedule 2 amend Health Insurance Determination HS/6/1999 to increase the fees for the services in that determination by 2 per cent.

Schedule 3

Schedule 3 amends Health Insurance Determination HS/03/2001 to increase the fees for the services in that determination by 2 per cent.

Schedule 4

Items 1, 2 and 3 of Schedule 4 amend Health Insurance Determination HS/01/2002 to increase the fees for the services in that determination by 2 per cent.

Schedule 5

Items 1 to 8 of Schedule 5 amend Health Insurance (Photodynamic Therapy) Determination HS/09/2002 to

- increase the fees for the services in that determination by 2 per cent;

- increase the limit on the number of photodynamic therapy treatments allowed under this determination from 10 to 15; and

- include two new items (42991 and 43000) to cover the 11th to 15th treatments.

Schedule 6

Items 1, 2, and 3 of Schedule 6 amend Health Insurance (Photodynamic Therapy) Determination HS/10/2002 to increase the fees for the services in that determination by 2 per cent.

Schedule 7

Schedule 7 amends Health Insurance (Botulinum Toxin) Determination HS/04/2003 to change the date of cessation from 30 April 2006 to the beginning of 1 November 2005.

Schedule 8

Items 1 to 10 of Schedule 8 amend Health Insurance (Deep Brain Stimulation for Parkinson’s Disease) Determination HS/01/2005 to:

- increase the fees for the services in that determination by 2 per cent;

- change the date of cessation from 30 April 2006 to the beginning of 1 November 2006;

- add St Vincents Private Hospital, Victoria, to the list of relevant centres where the services may be performed; and

- remove the restriction on item 40862 that the service must be performed in one of the ‘relevant centres’ listed in the above determination.

Schedule 9

Items 1 and 2 of Schedule 9 amend Health Insurance (Allied Health and Dental Services) Determination 2005, to increase the fees for the services in that determination by 2 per cent.

Overview

The Health Insurance (Amendment) Determination HS/04/2005 was introduced to address the need for adjustments to fees and provisions related to certain health services not explicitly listed in the Medicare Benefits Schedule. Enacted under the Health Insurance Act 1973, this Determination allows for specified health services to be treated as if they were listed in the Medicare Benefits Schedule under certain conditions. The primary objective of this legislative instrument is to ensure that the fees for these health services are aligned with the general fee increase of 2.0 percent applied to the Medicare Benefits Schedule from 1 November 2005. This amendment was necessary to accommodate the evolving landscape of healthcare services and to ensure the timely provision of necessary medical treatments. The amendments also address specific provisions such as increasing the number of treatments allowed for photodynamic therapy and adjusting the cessation dates for certain services, ensuring that healthcare providers and patients are adequately informed and prepared for these changes.

Scope and Application

The Health Insurance (Amendment) Determination HS/04/2005 amends several previous health insurance determinations to increase fees for specified health services, aligning them with a general fee increase of 2.0 percent applied to the Medicare Benefits Schedule (MBS) from 1 November 2005. This amendment affects health services that were previously determined under subsection 3C(1) of the Health Insurance Act 1973 and are not listed in the MBS, such as bone densitometry testing, grafting of infrarenal abdominal aortic aneurysm, treatment by hyperbaric oxygen therapy, sacral nerve stimulation services, and photodynamic therapy. The Determination also adjusts the cessation date for botulinum toxin services, from 30 April 2006 to 1 November 2005, due to the approval of relevant indications by the Therapeutic Goods Administration. Furthermore, it extends the cessation date for deep brain stimulation services for Parkinson’s disease from 30 April 2006 to 1 November 2006, adds St Vincents Private Hospital, Victoria, to the list of relevant centres for deep brain stimulation, and removes the restriction on the service being performed in listed centres. Additionally, the Determination increases the limit on the number of photodynamic therapy treatments from 10 to 15 and introduces two new items to cover the 11th to 15th treatments. The Determination is effective from 1 November 2005 and is a legislative instrument under the Legislative Instruments Act 2003.

Key Provisions

The Health Insurance (Amendment) Determination HS/04/2005 amends several existing section 3C determinations under the Health Insurance Act 1973, primarily focusing on increasing fees and modifying certain conditions for specified health services. The amendments are detailed in various schedules attached to the Determination, each targeting specific health services for adjustments (Clause 3). For instance, Schedules 1 to 6 and Schedule 9 increase fees for services such as bone densitometry testing, grafting of infrarenal abdominal aortic aneurysm, treatment by hyperbaric oxygen therapy, sacral nerve stimulation services, photodynamic therapy, and allied health and dental services by 2% (Schedules 1-6, 9). Schedule 5 further adjusts the photodynamic therapy services to allow up to 15 treatments per patient and introduces new items to cover additional treatments. The Determination also imposes several changes to the conditions under which these services are provided. For example, Schedule 7 extends the cessation date for deep brain stimulation for Parkinson’s disease from 30 April 2006 to 1 November 2006, allowing more time for a review by the Medical Services Advisory Committee (MSAC). Additionally, it adds St Vincents Private Hospital, Victoria, to the list of relevant centres where these services can be performed and removes the restriction that the service must be performed in one of these centres (Schedule 8). Similarly, Schedule 8 modifies the botulinum toxin determination by changing the cessation date from 30 April 2006 to 1 November 2005 to align with the transfer of these services to the Medicare Benefits Schedule (MBS) (Schedule 7). In terms of obligations and requirements, the Act and the Determination impose specific duties on healthcare providers, hospitals, and other entities involved in delivering these health services. Providers must ensure that their services align with the updated fee structures and conditions outlined in the Determination. For services like deep brain stimulation and photodynamic therapy, providers must adhere to the new limits on treatment numbers and the inclusion of additional treatment items. They must also ensure that services are performed in approved centres where necessary, or under the revised conditions as specified in the Determination. Failure to comply with the provisions of the Determination may lead to various consequences. While the Determination itself does not explicitly outline specific penalties, breaches of the Health Insurance Act 1973 can result in civil or criminal penalties. For instance, providing misleading or false information to obtain benefits could result in fines or imprisonment under the Act. Additionally, healthcare providers and entities that fail to adhere to the updated fee structures and conditions may face financial penalties or be subject to audits and investigations by relevant authorities.

Area of Law: Health Law
Instrument: Regulation
Concepts: Reporting & Disclosure Obligations; Fee Adjustments; Amendment of Existing Determinations

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