EXPLANATORY STATEMENT
Issued by the Authority of the Minister for Health and Ageing
Health Insurance Act 1973
Health Insurance (Extended Medicare Safety Net - Telehealth) Amendment Determination 2011
Purpose and Operation
Section 10B of the Health Insurance Act 1973 (the Act) provides that the Minister for Health and Ageing may, by legislative instrument, determine to which items of the Medicare Benefits Schedule (MBS) subsections 10ACA(7A) and 10ADA(8A) of the Act apply and the maximum increase in Medicare benefit payable for those items under the Extended Medicare Safety Net (EMSN). The increase in the Medicare benefit payable for those items under the EMSN is commonly referred to as the ‘EMSN benefit’.
Subsections 10ACA(7A) and 10ADA(8A) of the Act provide that where an item is listed in a determination made under section 10B of the Act, the EMSN benefit must not exceed the amount determined in relation to that item (“the EMSN benefit cap”).
The Health Insurance (Extended Medicare Safety Net - Telehealth) Amendment Determination 2011 (the Determination), will amend the Health Insurance (Extended Medicare Safety Net) Determination 2009. The Determination will introduce EMSN benefit caps on Medicare Benefits Schedule (MBS) items 13210 and 16399. These new MBS items were created through the Health Insurance (Telehealth Services) Determination 2011 (the 3C Determination) made pursuant to subsection 3C of the Act. These items enable some obstetric and assisted reproductive technology services to be provided by a specialist via video conference to a patient in an eligible area when claimed with an associated attendance item. The Determination will place a cap on these new items in accordance with the EMSN caps that exist for the associated items that they must be claimed with. This will ensure the integrity of the EMSN.
Background
The EMSN provides an increased Medicare rebate for Australian families and singles who incur
out-of-pocket costs for Medicare eligible out-of-hospital services and is provided for in sections 10ACA and 10ADA of the Act. The out-of-pocket cost is the difference between the fee charged by the doctor and the standard Medicare rebate (including any benefit received through the original Medicare safety net) that the patient receives from Medicare. Once the relevant annual threshold of out-of-pocket costs has been reached, Medicare will pay 80% of any future out-of-pocket costs for Medicare eligible out-of-hospital services for the remainder of the calendar year. However, where an item has an EMSN benefit cap, there is a maximum benefit payable for that item. For the 2011 calendar year, the annual EMSN threshold for concession cardholders and people who receive Family Tax Benefits (Part A) is $578.60. For all other singles and families the annual threshold is $1,157.50. These amounts are indexed by Consumer Price Index on 1 January each year.
As part of its 2010 Federal election platform, the Government announced a major initiative to expand the provision of telehealth services: Connecting Health Services with the Future: Modernising Medicare by Providing Rebates for Online Consultations. Under this initiative, the Government has committed to providing, from 1 July 2011, Medicare rebates for online consultations across a range of medical specialties. The initiative intends to address some of the barriers to accessing medical services, and specialist services in particular, for Australians in remote, regional and outer metropolitan areas, and in residential aged care facilities and Aboriginal Medical Services.
Effect of the Health Insurance (Extended Medicare Safety Net - Telehealth) Amendment Determination 2011
This Determination amends the Health Insurance (Extended Medicare Safety Net) Determination 2009 to introduce EMSN benefit caps on the two new telehealth ART and obstetric items. These new items, 13210 and 16399, have been created through the 3C Determination made under the Act and will be effective from 1 July 2011. These new items will be claimed in conjunction with existing items when the service described by those existing items is provided by video conference.
The EMSN benefit cap is the maximum amount of benefit payable under the EMSN, regardless of the fee that is charged by the practitioner. The EMSN benefit cap is payable in addition to the standard Medicare rebate (including any benefits received through the original safety net).
Placing EMSN benefit caps on these items means that EMSN benefits will be paid for the new items in addition to the EMSN benefits paid for the existing consultation items that the new items are claimed in association with. As the new telehealth items are derived fee items, Medicare processing rules dictate that the base item (the item with which the derived fee is claimed in association) and the derived fee item must both have an EMSN benefit cap for an EMSN benefit cap to apply to the overall claim. The effect of not placing an EMSN benefit cap on the new derived fee for the telehealth items would be that the base consultation items also no longer have an EMSN benefit cap when the claim is processed. The capping of the EMSN benefit for both items claimed for a video consultation supports appropriate clinical practice by avoiding the perverse incentive inherent in the situation where it is substantially more financially beneficial for a patient to receive the consultation remotely by video conference rather than face to face.
The fee for the new telehealth items will be 50% of the existing item fee to reflect the increased administrative and professional complexity that may come with a video consultation. As the existing ART and obstetric items all have existing EMSN caps the EMSN caps for the new telehealth items will also be set at 50% of the existing EMSN caps for the associated items.
The new telehealth ART item 13210 enables a Medicare benefit to be payable for the initiation of a professional attendance by a specialist via video conference, where that service relates to a service provided under existing MBS item 13209. As item 13209 has an existing EMSN benefit cap of $10, the new telehealth item 13210 will have a $5 EMSN cap. The new telehealth obstetric item 16399 enables a Medicare benefit to be payable for the initiation of a professional attendance by an obstetric specialist via video conference, where that service relates to a service provided under existing MBS item 16401, 16404, 16406, 16500, 16590 or 16591. All these items have varying EMSN caps so the EMSN cap placed on the new derived telehealth item is 50% of the weighted average of the existing EMSN caps for these items, which is $22.95.
This Determination will not have an impact on small business. The EMSN benefit is a patient benefit. Practitioners will not be required to complete any additional activities to comply with the change. EMSN benefit caps are automatically applied by Medicare Australia at the time that a patient’s claim is submitted.
The EMSN benefit cap amount for the new items will be made publicly available for patients and practitioners through the MBS Online website. This website is a commonly used resource which sets out item descriptors and the MBS Schedule fees and rebates for all Medicare items. The EMSN benefit cap will be clearly displayed in the item descriptors of the items to ensure that practitioners and patients are well informed of patient entitlements related to these particular Medicare services.
Details of the Determination can be found in the Attachment.
Financial Impact Statement
There is no additional financial impact for the introduction of this Determination.
Commencement
The provisions set out in the Determination will become effective from 1 July 2011.
Consultation
The Telehealth Advisory Group (TAG) has been consulted on the telehealth initiative. The TAG includes a representative from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the National Australian Society of Obstetricians and Gynaecologists.
ATTACHMENT
ATTACHMENT
Details of the Health Insurance (Extended Medicare Safety Net - Telehealth) Amendment Determination 2011.
1. Name of Determination
Section 1 provides that the name of the Determination is the Health Insurance (Extended Medicare Safety Net - Telehealth) Amendment Determination 2011.
2. Commencement
Section 2 provides that the Determination commences on 1 July 2011.
3. Amendments of the Health Insurance (Extended Medicare Safety Net) Determination 2009
Section 3 provides that Schedule 1 of the Determination amends the existing Health Insurance (Extended Medicare Safety Net) Determination 2009.
4. Schedule 1
Subsection 4(1) of the Health Insurance (Extended Medicare Safety Net) Determination 2009 sets out a table specifying the Medicare items from the GMST to which an EMSN benefit cap will apply and the amount of the EMSN benefit cap that will apply to each of those items.
This Determination amends that table to specify the EMSN benefit cap amount to apply to the new obstetric and ART telehealth attendance items (items 16399 and 13210 respectively).