EXPLANATORY STATEMENT
Issued by the Authority of the Minister for Health and Ageing
Health Insurance Act 1973
Health Insurance (Cataract Surgery) Determination 2009
Subsection 3C(1) of the Health Insurance Act 1973 (the Act) provides that the Minister may determine in writing that a health service not listed in an item in the General Medical Services Table (the Table) shall, in specified circumstances and for specified statutory provisions, be treated as if it were so listed. The Table is set out in the Health Insurance (General Medical Services Table) Regulations 2009 which are re-made each year.
A determination made under subsection 3C(1) of the Act is a legislative instrument (see subsection 3C(4) of the Act and paragraph 6(d) of the Legislative Instruments Act 2003).
The Health Insurance (Cataract surgery) Determination 2009 (the Determination) will permit the payment of Medicare benefits for cataract surgery.
The Determination provides for four items (item 42698, 42701, 42702 and 42718). Item 42698 will enable a Medicare benefit to be payable where a service for lens extraction is rendered. Item 42701 will enable a Medicare benefit to be payable where a service for the insertion of an artificial lens is rendered. Item 42702 will enable a Medicare benefit to be payable where a service for lens extraction and insertion of an artificial lens is rendered. Item 42718 will enable a Medicare benefit to be payable for the rendering of a service involving a complex lens extraction and insertion of an artificial lens with a surgical procedure time of 40 minutes or more.
This Determination has been made following the disallowance motion passed in the Senate on 28 October 2009 which disallowed items 42698, 42701, 42702 and 42718 from the Health Insurance (General Medical Services Table) Regulations 2009.
Details of the Determination are set out in the Attachment.
Consultation
Medicare Australia was consulted on the development of the new item for complex cataract procedures and the Royal Australian and New Zealand College of Ophthalmologists were consulted on the fee relativities for the cataract item structure and the new item for complex cataract procedures.
ATTACHMENT
Notes on sections in the Determination
Section 1
Section 1 provides the name of the Determination.
Section 2
Section 2 provides that the Determination commences on 1 November 2009.
Section 3
Section 3 defines terms used in this Determination. These terms are referred to in section 4 of the Determination.
Subsection 3(2) provides that a reference to a provision of an Act or Regulations, is a reference to the provision as in force from time to time.
Section 4
Subsection 4(a) provides that a relevant service specified in the Schedule to the Determination will be treated as if it were both a professional service and a medical service for the purposes of the provisions of the Act, the National Health Act 1953 and regulations made under each Act which provide for medical services or professional services.
Subsection 4(b) provides that a relevant service specified in the Schedule to the Determination is to be treated as if there were an item in Group T8 of the General Medical Services Table that related to the service and specified a fee for that service, being the fee specified in the Schedule to the Determination in relation to the service.
Schedule
The Schedule to the Determination sets out the relevant services, assigning the applicable item number, item descriptor and fee for each service.
Overview
The Health Insurance (Cataract Surgery) Determination 2009, enacted under the authority of the Minister for Health and Ageing, amends the Health Insurance Act 1973 to address the gap in Medicare benefits for cataract surgery services that were previously disallowed by a disallowance motion in the Senate. This Determination allows for the payment of Medicare benefits for specific cataract surgery services by treating these services as if they were listed in the General Medical Services Table. The objective of this Determination is to ensure that patients receive the necessary support through Medicare for cataract surgery, thereby improving access to essential healthcare services.
The Determination was developed following consultations with Medicare Australia and the Royal Australian and New Zealand College of Ophthalmologists, ensuring that the new items reflect appropriate fee relativities. This legislative instrument aims to provide clarity and consistency in the provision of cataract surgery services, facilitating the smooth operation of Medicare benefits for these procedures.
Scope and Application
The Health Insurance (Cataract Surgery) Determination 2009 applies to the provision of cataract surgery services in Australia and the payment of Medicare benefits for these services under the Health Insurance Act 1973. The Determination applies to persons who perform the specified services and to those who seek to claim Medicare benefits for these services. It is a legislative instrument that enables the payment of Medicare benefits for cataract surgery services by treating certain services as if they were listed in the General Medical Services Table. This Determination applies nationally across Australia, as it is a Commonwealth instrument. The Determination includes specified services related to cataract surgery and assigns item numbers and fees for each service, thereby providing clarity and eligibility for Medicare benefits. The Determination was developed following consultation with relevant stakeholders, including Medicare Australia and the Royal Australian and New Zealand College of Ophthalmologists, to ensure the accuracy and appropriateness of the services and fees included. The application of this Determination may be further extended or modified through subordinate instruments, as authorised by the Act.
Key Provisions
The Health Insurance (Cataract Surgery) Determination 2009 (the Determination) outlines specific provisions that enable the payment of Medicare benefits for various cataract surgery services. Under this Determination, four items are defined, each corresponding to different aspects of cataract surgery: Item 42698 pertains to the extraction of a lens, Item 42701 relates to the insertion of an artificial lens, Item 42702 encompasses both lens extraction and the insertion of an artificial lens, and Item 42718 is for complex lens extraction and insertion of an artificial lens, with a surgical procedure time of 40 minutes or more. The Determination was enacted following the disallowance of these items from the Health Insurance (General Medical Services Table) Regulations 2009, and it provides a clear pathway for the payment of Medicare benefits for these specified services.
This Determination imposes certain obligations on the parties involved. Firstly, the relevant services specified in the Schedule must be treated as if they were both professional and medical services under the Health Insurance Act 1973, the National Health Act 1953, and any regulations made under these Acts. Secondly, these services must be regarded as if they were listed in Group T8 of the General Medical Services Table, with fees specified in the Schedule to the Determination. The terms used in the Determination are defined in Section 3, and these definitions apply to all provisions of the Act and related regulations.
Breach of the provisions outlined in the Determination can lead to various consequences. While the Determination does not explicitly outline specific penalties, failure to comply with the Act's requirements for the payment of Medicare benefits can result in civil or criminal penalties. Under the Health Insurance Act 1973, penalties for fraudulent claims or misrepresentation can include fines and imprisonment. The maximum penalties for such offences are significant, reflecting the importance of compliance with Medicare regulations. The Act also provides for the recovery of any overpaid benefits, which can be pursued through the courts. Therefore, adherence to the Determination is crucial to avoid potential legal and financial repercussions.