Health Insurance Legislation Amendment (2025 Measures No. 2) Regulations 2025

EXPLANATORY STATEMENT

Health Insurance Act 1973

Health Insurance Legislation Amendment (2025 Measures No. 2) Regulations 2025

The Health Insurance Act 1973 (the Act) sets out the principles and definitions governing the Medicare Benefits Schedule (MBS). The Act provides for payments by way of medical benefits and for other purposes.

Subsection 133(1) of the Act provides that the Governor‑General may make regulations, not inconsistent with the Act, prescribing all matters required or permitted by the Act to be prescribed, or necessary or convenient to be prescribed for carrying out or giving effect to the Act.

Part II of the Act provides for the payment of Medicare benefits for professional services rendered to eligible persons. Section 9 of the Act provides that Medicare benefits be calculated by reference to the fees for medical services set out in prescribed tables.

Section 4AA of the Act provides that regulations may prescribe a table of diagnostic imaging services which sets out items of diagnostic imaging services, the fees applicable for each item, and rules for interpreting the table. The table made under this section is referred to as the Diagnostic Imaging Services Table.  The most recent version of the regulations is the Health Insurance (Diagnostic Imaging Services Table) Regulations (No. 2) 2020 (DIST).

Subsection 4(1) of the Act provides that regulations may prescribe a table of general medical services which sets out items of general medical services, the fees applicable for each item, and rules for interpreting the table. The table made under this subsection is referred to as the General Medical Services Table. The most recent version of the regulations is the Health Insurance (General Medical Services Table) Regulations 2021 (GMST).

Section 4A of the Act provides that regulations may prescribe a table of pathology services which set out items of pathology services, the fees applicable for each item, and rules for interpreting the table. The table made under this section is referred to as the Pathology Services Table. The most recent version of the regulations is the Health Insurance (Pathology Services Table) Regulations 2020 (PST).

The Health Insurance Regulations 2018 (HIR) provide the overarching policy framework supporting the provision of appropriate Medicare services. For the purposes of paragraph 10(2)(aa) of the Act, section 28 of the HIR prescribes items that have a Medicare benefit equal to 100 per cent of the fee in respect of the service.

Purpose

The purpose of the Health Insurance Legislation Amendment (2025 Measures No. 2) Regulations 2025 (the Regulations) is to amend the DIST, GMST and PST immediately after the commencement of the Health Insurance Legislation Amendment (Indexation) Regulations 2025 on 1 July 2025. The Regulations will introduce and amend MBS items as agreed to in the 2024-25 Budget 2023-24, the Mid-Year Economic and Fiscal Outlook (MYEFO) and the 2023-24 Budget. Additionally, the Regulations will implement administrative and machinery changes to the DIST and the GMST. Further detail can be found in the Attachment.

The Regulations will:

• amend two whole body fluorodeoxyglucose (FDG) positron emission tomography PET study items to remove the definition of rare or uncommon cancer;
• change the eligibility requirements for diagnostic imaging equipment;
• make consequential changes to the DIST to remove a reference to the Royal Australian and New Zealand College of Radiologists (RANZCR) Quality and Accreditation Program and remove an item from a maximum claiming limit;
• amend a urine examination pathology test to restrict testing to symptomatic and some asymptomatic patients to reduce clinically unnecessary testing;
• amend two vitamin B12 pathology tests and list a new vitamin B12 pathology item for more frequent testing to clarify the appropriate testing pathway of vitamin B12;
• introduce new and amend existing MBS items for ophthalmology services as recommended by the MBS Review Taskforce or Medical Services Advisory Committee (MSAC);
• make consequential changes to items 104 and 105 as a result of two new gynaecology long consultation items (items 125 and 126) for patients with complex conditions;
• make consequential changes to items 132 and 133 as a result of new and amended changes to specialist and consultant physicians telehealth items;
• add a co-claiming restriction to item 92614 for telehealth attendance by a specialist in the practice of neurosurgery;
• make an administrative amendment to change the definition of ‘Telehealth and Telephone Determination’;
• insert items 125 and 126 into Group A3 of the GMST to provide gynaecology long consultation items for patients with complex conditions; and
• amend ten radiation oncology items for megavoltage treatment to clarify how often the items can be claimed, to update referenced item numbers, and to make further minor corrections in line with original policy intent.

Consultation

The Department of Health, Disability and Ageing consulted with key stakeholders on the Regulations, and stakeholders were generally supportive of the changes being implemented by the Regulations.

For changes to the DIST, stakeholders included:

• Australian College of Rural and Remote Medicine
• Australian Diagnostic Imaging Association (ADIA)
• Australian Genomic Cancer Medicine Centre
• Australian Medical Association (AMA)
• Australian Society of Medical Imaging and Radiation Therapy
• Cancer Council Australia
• Clinical Oncology Society of Australia
• Consumer Health Forum
• Medical Oncology Group of Australia
• Private Cancer Physicians of Australia
• Prostate Cancer Foundation of Australia
• Royal Australasian College of Physicians
• Royal Australasian College of Surgeons
• Royal Australian College of General Practitioners
• RANZCR
• Urological Society of Australian and New Zealand

For changes to the GMST, stakeholders included:

• Audiology Australia
• Australian College of Nurse Practitioners (ACNP)
• Australian College of Nursing
• Australian College of Optometry
• Australian College of Rural and Remote Medicine
• AMA
• Australian Paediatric Society
• Australian Physiotherapy Association
• Australian Private Hospitals Association (APHA)
• Australian Society of Ophthalmologists
• Boston Scientific
• Consumers Health Forum of Australia
• Day Hospitals Australia
• Dietitians Association of Australia
• Exercise and Sports Science Australia
• Hearts4Heart
• Indigenous Allied Health Australia
• Interventional Craft Group at the Victorian Heart and Eastern Heart Clinic Group
• Lions Eye Institute
• Macular Disease Foundation Australia
• Optometry Australia
• Private Healthcare Australia
• Radiation Oncology Access Coalition
• Royal Australian and New Zealand College of Ophthalmologists
• Royal Australian College of General Practitioners (RACGP)
• RANZCR
• Services for Australian Rural and Remote Allied Health
• Vision 2020 Australia
• Individual medical specialists

For changes to the PST, stakeholders included:

• Australasian Sonographers Association
• Australian and New Zealand Society for Geriatric Medicine
• Australian and New Zealand Society of Nephrologists
• ACNP
• ADIA
• Australian Medical Association
• Australian Pathology
• APHA
• Consumers Health Forum
• NPS Medicinewise
• NSW Health Pathology
• Public Pathology Australia
• RACGP
• Royal Australian College of Physicians
• Royal College of Pathologists of Australasia
• RANZCR

For changes to the HIR, stakeholders included:

• ADIA
• AMA
• Cancer Australia
• Lung Foundation Australia
• National Aboriginal Community Controlled Health Organisation
• NLCSP Expert Advisory Committee
• RANZCR
• RACGP
• State and Territory governments
• Thoracic Society of Australia and New Zealand

The Act specifies no conditions that need to be satisfied before the power to make the Regulations may be exercised.

Details of the Regulations are set out in the Attachment.

The Regulations are a legislative instrument for the purposes of the Legislation Act 2003.

The Regulations will commence immediately after the commencement of the Health Insurance Legislation Amendment (2025 Measures No. 2) Regulations 2025.

                                                                     Authority:  Subsection 133(1) of the

                                                                                         Health Insurance Act 1973 

ATTACHMENT

Details of the Health Insurance Legislation Amendment (2025 Measures No. 2) Regulations 2025

Section 1 – Name

This section provides for the Regulations to be referred to as the Health Insurance Legislation Amendment (2025 Measures No. 2) Regulations 2025 (the Regulations).

Section 2 – Commencement

This section provides for the Regulations to commence immediately after the commencement of the Health Insurance Legislation Amendment (2025 Measures No. 2) Regulations 2025.

Section 3 – Authority 

This section provides that the Regulations are made under the Health Insurance Act 1973 (the Act).

Section 4 – Schedules

This section provides that each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.

Schedule 1

Part 1—Diagnostic imaging services table

Health Insurance (Diagnostic Imaging Services Table) Regulations (No. 2) 2020 (DIST)

Items 1 and 2 amend items 61612 and 61614 of the DIST, which are both whole body fluorodeoxyglucose (FDG) positron emission tomography (PET) study items, by repealing and substituting the current cells at column 2 of items 61612 and 61614 to remove the definition of rare or uncommon cancer in those items. Currently, item 61612 is for the initial staging of “eligible cancer types” and item 61614 describes a follow up service for assessment of treatment response and recurrence for these rare and uncommon cancers, where the “eligible cancer types” for these items are limited to rare or uncommon cancers.

The amendments to items 61612 and 61614 will expand the group of patients eligible for the services described in these items by referring to the clinical term “typically FDG-avid cancer”, which captures any cancer that is appropriate for FDG PET study, rather than “eligible cancer types” that are also a “rare or uncommon cancer”.

Items 3 to 9 make amendments to the DIST to update the equipment provisions for certain diagnostic imaging services. These amendments remove the barriers to accessing Medicare rebates for certain magnetic resonance imaging (MRI) machines in metropolitan areas to reduce waiting times and costs for patients.

Currently, MRI machines can be classified as fully or partially eligible. Medicare-eligible MRI machines in Modified Monash (MM) 1 areas are either fully or partially eligible, while Medicare eligible MRI machines in MM 2 to 7 are fully eligible. Medicare eligibility for MRI equipment in MM1 areas is subject to a deed that the Government enters with the proprietor of the diagnostic imaging practice. Fully Medicare-eligible MRI machines have no conditions on the requestor or patient and will attract a Medicare benefit if the requirement of the MRI service is met. Partially eligible MRI machines have conditions on the type of services they can render, meaning they can only render a subset of the MRI services in the DIST.

From 1 July 2025, the Regulations will implement a Government decision to replace all deeds with proprietors of practices with fully or partially eligible MRI machines with new deeds that confer full Medicare eligibility to all MRI equipment at the practice level.

Item 3 repeals subclause 2.5.1(2) of Schedule 1, as it relates to the use of partially eligible diagnostic imaging equipment for certain Medicare Benefits Schedule (MBS) services in MM 1 areas under clause 2.5.6 of Schedule 1. As noted below, clause 2.5.6 will also be repealed by item 6 of the Regulations, rendering subclause 2.5.1(2) no longer relevant.

Item 4 omits the words “partially eligible equipment in clause 2.5.6”, making a consequential amendment to reflect that clause 2.5.6 of Schedule 1 will be repealed by item 6 from 1 July 2025.

Item 5 repeals and replaces the current clause 2.5.5. This will provide that for the purposes of clause 2.5.1, equipment is eligible equipment if it is included on the Diagnostic Imaging Register in relation to the location specific practice number for the comprehensive practice at which is located, and made available to the practice by a person who is subject to a current deed with the Commonwealth that relates to the equipment so included on the Register.

Item 6 repeals clause 2.5.6. Currently, clause 2.5.6 provides the requirements for partial eligibility for diagnostic imaging equipment. From 1 July 2025, this amendment will implement a Government decision to replace all deeds with proprietors of practices with fully or partially eligible MRI machines, with new deeds that confer full Medicare eligibility to all MRI equipment at the practice level.

Item 7 and 8 make administrative changes to clause 2.5.14 to insert references to Subgroup 32 of the DIST (which deals with magnetic imaging resonance imaging for PIP breast implant) into the heading and body of that clause. These changes are machinery in nature and are intended to update clause 2.5.14 to accurately include reference to all subgroups listed in the table at clause 2.5.14.

Item 9 inserts a new Division 3 into Part 4 of Schedule 1 of the DIST to introduce new provisions relating to capital sensitivity requirements for relevant MRI equipment. The new provisions are as follows:

• Clause 4.6, which sets out definitions (including a definition of the term “relevant MRI equipment”),
• Clause 4.7, which deals with the applicable life age and restriction on items for relevant MRI equipment, providing that the applicable life age for relevant MRI equipment is the maximum extended life age of the equipment if subclause 4.7(2) or (3) applies,
• Clause 4.8, which deals with applications for validation of subsequently improved equipment where equipment was unable to be improved before the commencement day (being the date the Regulations commence),
• Clause 4.9, which deals with granting validation of subsequently improved equipment where equipment was unable to be improved before the commencement day, and
• Clause 4.10, which deals with reconsideration by the Secretary of a refusal to validate relevant MRI equipment.

Item 10 amends paragraph 1.2.2(4)(c) to replace the phrase “is currently” with “has been”. This is to reflect the advice from the Royal Australian and New Zealand College of Radiologists (RANZCR) that it intends to cease its Mammography Quality and Accreditation Program (MQAP) early in 2025. As such, it is a requirement that diagnostic imaging equipment ‘has been’ accredited under RANZCR’s MQAP (rather than ‘is currently’ in order to be ‘upgraded’ for the purposes of clause 1.2.2(4) of the DIST.

Item 11 and 12 repeals and substitutes the cells at items 60506 and 60509, column 2 to make minor typographical amendments, including to insert a comma after the word “Fluoroscopy”, and to insert paragraphs in the cell to make it a condition that the fluoroscopy to which these items apply “lasts less than 1 hour” and “is in conjunction with a surgical procedure”. These adjustments aim to clarify the long-standing interpretation regarding the time component use of these imaging services in conjunction with surgical procedures, and they are intended to clarify that the time element specified in these services pertains to the duration of the provision of the fluoroscopy service rather than the duration of the surgical procedure itself.

Item 13 makes a minor administrative amendment to paragraph 2.4.5(1)(b) by replacing the word “in” with “is”, correcting a minor typographical error and clarifying that the place where the owner or operator of relevant diagnostic imaging equipment is a comprehensive facility.

Item 14 amends the table at clause 2.5.4 by repealing the cell at table item 1, column 2 and substituting the phrase “A person who is a specialist in diagnostic radiology”.  Currently, clause 2.5.4 sets out requirements for providers of MRI and magnetic resonance angiography (MRA) services and references a condition that the Chief Executive of Medicare (CEM) must be satisfied that the radiologist is a participant in the RANZCR Quality and Accreditation Program. This program will cease on 1 July 2025, as RANZCR have determined that this level of training is adequately addressed by any person who is a fellow of RANZCR, also known as “a person who is a specialist in diagnostic radiology”. As such, the reference to a person who satisfied the CEM that the specialist is a participant in the RANZCR Quality and Accreditation Program will be removed.

Item 15 amends the table at clause 2.5.9 at table item 9, column 1 to exclude item 63390 from the limitations provided by the clause. Clause 2.5.9 provides restrictions on MRI and MRA items. Item 63390 provides an MRI service for the diagnosis of myocarditis in patients with symptoms, and was first introduced to the MBS on 1 January 2025 by the Health Insurance (Section 3C Diagnostic Imaging Services – Cardiac MRI for Myocarditis) Determination 2024. Item 63390 should have been excluded from the limitations provided by clause 2.5.9 on this date, as no limitation was intended to be applied to this service as clinicians should be able to request this service where myocarditis is suspected. This change will align clause 2.5.9 with the original policy intent for item 63390.

Part 2—General medical services table

Health Insurance (General Medical Services Table) Regulations 2021 (GMST)

Item 16 amends item 11000 in the GMST, which provides a service for electroencephalography, by amending paragraph (a) of the descriptor for item 11000 to include a co-claiming limitation with item 11205. This will prevent item 11000 being claimed together with item 11205 (in addition to item 11009).

Item 17 amends the descriptor for item 11000 to provide that the (Anaes.) flag applies to the entirety of the item descriptor in column 2, rather than only applying to paragraph (b) of the item descriptor.

Item 18 amends the descriptor for item 11205, which describes a service for electrooculography of one or both eyes performed by a specialist or consultant physician, in the practice of the specialist’s or consultant physician’s specialty. This item provides that item 11205 cannot be claimed together with item 11000, 11340, 11341 or 11343. 

Item 19 amends the descriptor for item 11210, which describes a service for pattern electroretinography of one or both eyes by computerised averaging techniques, to provide that the service described in item 11210 can only be performed by or on behalf of a specialist or consultant physician, in the practice of the specialist’s or consultant physician’s specialty.

Item 20 amends the descriptor for item 11211, which describes a service for dark adaptometry of one or both eyes with a quantitative estimation of threshold in log lumens at 45 minutes of dark adaptations, to provide that the service described in this item is only able to be performed by or on behalf of a specialist in the practice of the specialist’s specialty of ophthalmology.

Items 21 and 22 amend the descriptor for item 15930, which describes a service for megavoltage treatment at level 1.1 for radiation therapy for simple, single-field treatment, to replace the word “with” with the words “to implement” in paragraph (c) of that item. This is a minor administrative change to resolve an inconsistency in the descriptor for item 15930. Item 21 inserts an applicability limitation in item 15930, to provide that the service described in item 15930 is capable of being provided to a patient up to twice per plan per day.

Item 23 amends paragraph (d) of the descriptors for items 15932, 15934 and 15936 to provide that the services described in each of these items are capable of being provided to a patient up to twice per day per plan. The services described in these items are:

• For item 15932 - megavoltage treatment (level 1.2) for radiation therapy and image verification for simple treatment, with imaging for field setting,
• For item 15934 – megavoltage treatment (level 2.1) for radiation therapy and image verification for three-dimensional treatment, without motion management, and
• For item 15936 – megavoltage treatment (level 2.2) for radiation therapy and image verification for three-dimensional treatment.

Item 24 amends the descriptor for item 15938, which describes a service for megavoltage treatment (level 3.1) for standard single-dose level intensity modulated radiation therapy (IMRT) treatment and image verification without motion management, to provide that the service described in item 15938 is capable of being provided to a patient up to twice per plan per day. This item also amends item 15938 to replace the phrase “a standard IMRT plan” with “an IMRT plan”, as there is no separate concept of a “standard” IMRT plan.

Items 25 and 26 amend the descriptor for item 15940, which describes a service for megavoltage treatment (level 3.2) for complex multiple-dose level IMRT treatment, or single dose-level IMRT treatment requiring motion management, and image verification. This item amends item 15940 to replace the words “a complex IMRT plan” with the words “an IMRT plan” to remove the concept of a “complex” IMRT plan, and amends item 15930 to replace the reference to “item 15914” with “item 15940” in specifying the level for which image-guided radiation therapy (IGRT) is used to implement an IMRT plan. Item 26 also amends the descriptor for item 15940 to provide that the service described in item 15940 is capable of being provided to a patient up to twice per plan per day.

Items 27 and 28 amend the descriptor for item 15942, which describes a service for megavoltage treatment (level 4) for intracranial stereotactic radiation therapy treatment and image verification, to omit the words “that is equivalent or higher than that” from paragraph (b). Paragraph (b) of item 15942 will therefore provide for IGRT to be used to implement a stereotactic body radiation therapy plan at a level described in item 15918, rather than at an equivalent or higher level. Item 28 also amends the descriptor for item 15942 to provide that the service described in item 15942 is applicable once per day.

Items 29 and 30 amend the descriptor for item 15944, which describes a service for megavoltage treatment (level 4) for stereotactic body radiation therapy (SBRT) treatment and image verification, to omit the words “that is equivalent or higher than that” from paragraph (b). Paragraph (b) of item 15944 will therefore provide for IGRT to be used to implement a SBRT plan at a level described in item 15920, rather than at an equivalent or higher level.  Item 30 also amends the descriptor for item 15944 to provide that the service described in item 15944 is applicable once per day.

Item 31 amends the descriptor for item 15946, which describes a service for megavoltage treatment (level 5) for specialised radiation therapy treatment and verification, to insert the words “to implement a treatment plan” after the word “used” in paragraph (b) of the descriptor. This is a minor administrative change to resolve an inconsistency in the descriptor for item 15946.

Additionally, this item will make an amendment to provide that the service described in item 15946 is applicable once per day.

Item 32 amends the descriptor for item 15948, which describes a service for megavoltage treatment (level 5) for specialised radiation therapy treatment and verification, by repealing and substituting the cell at column 2 for item 15948 to omit former paragraph (c), which required that image guided radiation therapy be used to implement three-dimensional radiation therapy, IMRT, or total skin electrons where there is individualised treatment.

Additionally, this item will make an amendment to provide that the service described in item 15948 is applicable once per day.

Items 33 to 73 implement changes to ophthalmology services in the GMST as recommended by the MBS Review or Medical Services Advisory Committee (MSAC), including amending existing items, deleting items in Group T8 of the GMST, and inserting new items into Group T8 of the GMST.

Item 33 repeals and substitutes the descriptor in column 2 for item 42504. Currently, item 42504 is limited to include micro-bypass glaucoma surgery device implantation in the trabecular meshwork region of the eye. The new descriptor for item 42504 will also include insertion of the device in the suprachoroidal space. The service will remain limited to patients who are contraindicated for conservative treatment (usually glaucoma eye drops) or who have failed, or are likely to fail, conservative treatment.

Item 34 amends the descriptor for item 42505 by replacing the words “from the eye of a trans‑trabecular drainage device or devices” with the words “of a micro‑bypass glaucoma surgery device or devices from the suprachoroidal space or the trabecular meshwork”. This will have the impact of aligning the terminology to that used in other items.

Item 35 amends the descriptor for item 42506 by replacing the phrase “with or without sphere” with “without insertion of”, to provide that the service described in item 42506 is for enucleation of the eye, without insertion of sphere implant.

Item 36 amends the descriptor for item 42509 by replacing the phrase “integrated implant” with “non-integrated implant, without muscle attachment”, to provide that the service described in item 42509 is for enucleation of the eye with insertion of non-integrated implant, without muscle attachment.

Item 37 repeals and substitutes the descriptor for item 42510. Currently, the service described in item 42510 is “Eye, enucleation of, with insertion of hydroxy apatite implant or similar coralline implant (H) (Anaes.) (Assist.)”. The new descriptor for item 42510 will, amongst other changes, replace the reference to a “hydroxy apatite implant” with a reference to “other integrated implant”; insert paragraphs into the descriptor; and specify that the service involves, in relation to a coralline implant, attachment of at least the 4 rectus muscles to the implant or the implant wrap.

Item 38 amends the descriptor for item 42530 to omit the words “with or without biopsy, requiring removal of bone” and instead substitute the words “of, requiring removal of bone (orbitotomy) for access, with subsequent drainage or biopsy, including repair of any bone or soft tissue surgical defect, other than a service associated with a service to which item 45590 or 45594 applies on the same side”. This will provide greater specificity about the service to which item 42530 applies operates and will introduce a co-claiming restriction for a service associated with a service to which item 45590 or 45594 applies on the same side.

Item 39 amends the descriptor for item 43533 to provide that the service is for exploration of orbit, without requiring removal of bone (orbitotomy) for access, with drainage or biopsy, including repair of any bone or soft tissue surgical defect.

Item 40 amends the descriptor for item 42536 to insert the words “including repair of any bone or soft tissue surgical defect,” after the words “exenteration of,”, clarifying that the service to which item 42536 applies extends to the repair of any bone or soft tissue surgical defect.

Item 41 amends the descriptor for item 42539 to provide that the service to which item 42539 applies is exploration of the orbit, requiring removal of bone (orbitotomy) for access, with removal of tumour or foreign body (not incisional biopsy), including repair of any bone or soft tissue surgical defect. 

Items 42 and 43 both amend the descriptor for item 42542. Item 42 makes a minor typographical edit to insert a comma after the word “aspect”. Item 43 amends the descriptor for item 42542 to provide that the service described in this item includes repair of any bone or soft tissue surgical defect, but does not extend to incisional biopsy.

Item 44 amends the descriptor for item 42590, which describes a service for medial or lateral canthoplasty, to specify that item 42590 does not apply where the service is performed in conjunction with cosmetic blepharoplasty.

Item 45 amends the descriptor for item 42623 to further specify that the dacryocystorhinostomy described in item 42623 applies to external or endonasal approach, including any sinus, turbinate or uncinate operation performed by same surgeon for access, with or without silicone intubation/stenting.

Items 46 and 47 amend the descriptor for item 42626, which describes a service for dacryocystorhinostomy if a previous dacryocystorhinostomy has been performed. Item 46 makes a minor typographical edit to insert a comma after the word “Dacryocystorhinostomy”. Item 47 amends the descriptor for item 42626, providing that the service applies to external or endonasal approach, including any sinus, turbinate or uncinate operation performed by same surgeon for access, with or without silicone intubation/stenting.

Item 48 repeals and substitutes the descriptor for item 42629. Currently, the service described in item 42629 is for “Conjunctivorhinostomy including dacryocystorhinostomy and fashioning of conjunctival flaps (H) (Anaes.) (Assist.)”. Instead, the new descriptor in column 2 for item 42629 will apply specifically for dacryocystorhinostomy, with placement of a permanent bypass tube from the conjunctival sac to the nasal cavity.

Item 49 amends the descriptor for item 42632, which describes a service for conjunctival peritomy or repair of corneal laceration by conjunctival flap, by inserting a co-claiming restriction after the word “flap”, such that the service described in in item 42632 can be claimed except for a service associated with a service to which item 42686 applies.

Item 50 amends the descriptor for item 42647, which describes a service for removal of corneal scars by partial keratectomy, to extend the current co-claiming restriction to a service associated with a service to which item 42650 applies.

Item 51 amends the descriptor for item 42650, which describes a service for epithelial debridement for corneal ulcer or corneal erosion, to insert a co-claiming restriction such that item 42650 is applicable to a service described in that item, other than a service associated with a service to which item 42647 applies.

Item 52 amends the descriptor for item 42686, which describes a service for the removal of the pterygium, to insert a co-claiming restriction such that item 42686 is applicable for a service described in that item, other than a service associated with a service to which item 42632 or 42647 applies.

Item 53 amends the descriptor for item 42705, which describes a service for lens extraction and insertion of intraocular lens, to omit the words “a trans-trabecular drainage device or devices” and instead substitute the words “insertion of a micro‑bypass glaucoma surgery device or devices into the suprachoroidal space or trabecular meshwork”.

Item 54 repeals and substitutes the cell at column 2 for item 42713 to provide that the item applies to ciliary body suturing in addition to iris suturing, and to provide that the service may be performed for fixation of intraocular lens, or repair or iris defect or cyclodialysis cleft. This item also amends the cell at column 2 for item 42713 to insert a “(H)” flag and to insert paragraphs into the descriptor for the service.

Item 55 amends the descriptor for item 42744 to replace the word “procedure” with “surgery”, such that item 42744 will describe a service for needle revision of glaucoma filtration bleb, following glaucoma filtering surgery.

Item 56 amends the descriptor for item 42746 to omit the words “, filtering operation for” and instead substitute the words “filtering surgery”, such that item 42746 will describe a service for glaucoma, filtering surgery, if conservative therapies have failed, are likely to fail, or are contraindicated.

Item 57 amends the descriptor for item 42749 to provide that the item applies to glaucoma, filtering surgery, if previous filtering surgery has been performed, replacing the former reference to a “filtering operation” with a “filtering surgery”. 

Item 58 repeals and substitutes the cell at column 2 for item 42752 to provide that the item applies to insertion of glaucoma drainage device incorporating an extraocular reservoir, removing the former reference to a drainage device “such as a Molteno device”.

Item 59 repeals and substitutes the cell at column 2 for item 42755 to provide that the item applies to any of, in relation to one eye, the removal of glaucoma drainage device incorporating an extraocular reservoir; insertion or removal of intraluminal stent; or tying off lumen.

Item 60 amends the descriptor for item 42773 to provide that the item applies to pneumatic retinopexy for detached retina as an independent procedure. This will remove the specific co-claiming restriction for a service associated with a service for which item 42776 applies, instead providing that the service described in item 42773 is to be performed as an independent procedure.

Item 61 amends the descriptor for item 42794 to make a minor grammatical edit, replacing the word “filtration” with “filtering” such that the service described in item 42794 will be for division of suture by lasering following glaucoma filtering surgery.

Item 62 amends the descriptor for item 42808, which is currently a service for laser peripheral iridoplasty, to omit the word “peripheral” such that item 42808 instead describes a service for laser iridoplasty.

Items 63 and 64 amend the descriptor for item 42818, which deals with cryotherapy to the retina. Item 63 inserts the phrase “or ciliary body,” after the word “Retina,” to provide that item 42818 also applies to the ciliary body. Item 64 amends the descriptor for item 42818 to omit the current phrase “in association with item 42770 or 42809” and substitute “in conjunction with item 42809” to provide that item 42818 applies to a service when performed in conjunction with item 42809 only (rather than also item 42770).

Items 65 and 66 amend the descriptor for item 42863, which deals with recession of the eyelid. Item 65 inserts the words “(upper or lower)” after the word “Eyelid” to specify that item 42863 applies to a service for the upper or lower eyelid. Item 66 amends the descriptor for item 42863 to insert the phrase “, by open operation on and direct release of the lid retractors, one eye” after the word “of” to specify how the service in item 42863 is to occur.

Item 67 amends the descriptor for item 42866, which provides for repair of the entropion or tarsal entropion, by specifying that item 42866 applies to the service, excluding when the service is performed in conjunction with closure of the retractors using conjunctival approaches for fat pad reduction or orbital surgery. 

Item 68 repeals and substitutes the cell at column 2 for item 42872, such that item 42872 will apply to a service for direct eyebrow lift in paretic states or in involutional states if specified conditions set out in paragraphs (a) and (b) of the descriptor for the service are met.

Item 69 amends the descriptor for item 45590, which describes a treatment for wall or floor of the orbital cavity, with or without bone graft, cartilage graft or foreign implant, to insert the words “42530 or” after the word “item”. This will have the effect of providing that the co-claiming restriction currently in place for item 45594 also extends to item 42530, such that a service to which item 45590 applies cannot be claimed where a service associated with a service to which item 42530 or 45594 applies on the same side.

Item 70 amends the descriptor for item 45594, which describes exploration of wall or floor of the orbital cavity, without bone graft, cartilage graft or foreign implant, to insert “42530,” after the word “item”. This will have the effect of providing that the co-claiming restriction currently in place for items 45590 and 45592 also extend to item 42530, such that a service to which item 45594 applies cannot be claimed where a service associated with a service to which item 45590 or 45592 applies on the same side.

Item 71 repeals items 42524, 42593, 42738, 42739, 42740, 42741, 42806, 42807 and 43023 from Schedule 1 to the GMST. Repealed items 42738, 42739 and 42740, which did not differentiate between the left and right eyes, will be replaced by new items 43030, 43034 and 43038 (relating to treatments specifying the left eye) and 43032, 43036 and 43030 (relating to treatments specifying the right eye), as set out below for item 73. 

Item 72 inserts new item 42750 into the GMST after item 42749. New item 42750 will provide for subconjunctival injection of antifibrotic agent following glaucoma filtering surgery, as an independent procedure.

Item 73 adds new ophthalmology items 43030, 43032, 43034, 43036, 43038, 43040 and 43050 into the end of Subgroup 9 of Group T8 of the GMST. As noted above for item 71, new items 43030, 43034 and 43038 (relating to treatments specifying the left eye) and 43032, 43036 and 43040 (relating to treatments specifying the right eye) will replace former items 42738, 42739 and 42740. New item 43050 will provide for repair of choroidal detachment by external drainage.

Item 74 repeals the definition of Telehealth and Telephone Determination in clause 7.1.1 of Schedule 1 to the GMST.

Item 75 inserts a new definition of Telehealth Attendance Determination into clause 7.1.1 of Schedule 1, where Telehealth Attendance Determination will mean the Health Insurance (Section 3C General Medical Services – Telehealth Attendances) Determination 2021.

Item 76 makes administrative changes to omit the phrase “and Telephone” (wherever occurring) and substitute “Attendance” for the following provisions in the GMST:

 (a) Schedule 1 (item 228, column 2, paragraph (b));

 (b) Schedule 1 (item 792, column 2, note);

 (c) subclause 2.16.12A(2) of Schedule 1 (table);

 (d) subclauses 2.20.6(8A), (8B), (8C) and (8D) of Schedule 1;

 (e) subsubparagraph 2.20.7A(2)(a)(i)(C) of Schedule 1.

Item 77 amends clause 1.1.5 of the GMST to make a minor typographical change by omitting the word “dieticians” in paragraph (g) of the ‘Example’ in subsection (2) and instead replacing it with the word “dietitians”.

Item 78 amends subclause 1.2.4(1), which applies to particular specialist attendance items to prevent the claiming of these attendances items where a doctor performs a service to which an item in Group T8 of the GMST applies (a procedure) with a fee greater than $349.95 on the same day for the same patient, to insert item 92614 after item 92613. This will have the effect of extending the application of subclause 1.2.4(1) to apply to item 92614.

Item 79 amends the descriptor for item 104 to make a consequential amendment to insert “, 125” after “109”. This consequential amendment will reflect the insertion of new item 125 at the end of Group A3 of the GMST by item 81 below.

Item 80 amends the descriptor for item 105 to make a consequential amendment to insert the words “126 or” after the word “item”. This consequential amendment will reflect the insertion of new item 126 at the end of Group A3 of the GMST by item 81 below.

Item 81 inserts new item 125 at the end of Group A3 of the GMST, in order to introduce new item 125 to the MBS on 1 July 2025. New item 125 provides an initial attendance by a gynaecologist for an attendance lasting 45 minutes or longer. The item descriptor for new item 125 will stipulate that the service cannot be claimed if the gynaecologist has rendered an attendance service to which item 104 applies for the same patient on the same day as part of the same single course of treatment, which allows co-claiming where the patient is presenting for an unrelated matter.

This item will also insert new item 126 at the end of Group A3 of the GMST, in order to introduce new item 126 to the MBS on 1 July 2025. New item 126 will provide for a subsequent attendance by a gynaecologist for an attendance lasting 45 minutes or longer. The item descriptor for new item 126 will stipulate that the service cannot be claimed if the gynaecologist has rendered an attendance service to which item 105 applies for the same patient on the same day as part of the same single course of treatment, which allows co-claiming where the patient is presenting for an unrelated matter.

Item 82 amends the descriptors for both items 132 and 133 to make consequential changes to add consultant physician video attendance items 91824, 91825 and 91826 and phone attendance item 91836 to the limitation of attendances that consultant physicians can perform. Item 132 describes professional attendance by a consultant physician in the practice of their specialty (other than psychiatry), lasting at least 45 minutes for an initial assessment of a patient with at least 2 morbidities. Item 133 describes professional attendance by a consultant physician in the practice of their specialty (other than psychiatry), lasting at least 20 minutes after the initial attendance in a single course of treatment for a review of a patient with at least 2 morbidities.

Item 83 amends clause 2.16.18 of the GMST to make a minor typographical change by omitting the word “dieticians” in paragraph (a) of the ‘Example’ and instead replacing it with the word “dietitians”.  

Item 84 inserts new item 38326 into Subgroup 6 of Group T8 of the GMST. New item 38326 will provide for the use of optical coherence tomography during transluminal insertion of stents to optimise procedural strategy, appropriate stent size and assessment of stent apposition, if performed in association with a service to which other specified items apply and if other specified conditions in paragraphs (a), (b) or (c) of new item 38326 are met. The insertion of this new item will be in accordance with a recommendation from MSAC.

Item 85 amends clause 7.1.1 of the GMST to insert new paragraphs (aa) and (ab) into the definition of eligible allied health provider in clause 7.1.1, which will include a dietitian and an exercise physiologist, respectively, in the definition. This will be a consequential amendment to reflect a determination made under section 3C of the Act to amend allied health items in the Health Insurance (Section 3C General Medical Services – Allied Health Services) Determination 2024 and the Health Insurance (Section 3C General Medical Services – Telehealth and Telephone Attendances) Determination 2021 to enable services to be rendered by eligible dietitians and exercise physiologists to patients with complex neurodevelopmental disorders and eligible disabilities.

Part 3—Pathology services table

Health Insurance (Pathology Services Table) Regulations 2020 (PST)

Item 86 repeals and substitutes the cell at column 2 for item 66838 of the PST to allow for requestors to request testing of total vitamin B12, or testing of holotranscobalamin, or testing of both. This amendment will provide options for first line testing of patients, as based on best clinical practice. This amendment will also reduce the limitation of the frequency of the test from once every 12 months to once every 11 months.

Item 87 repeals and substitutes the cell at column 2 for item 66839 for testing of specific markers if a patient’s initial test result from a test performed under item 66838 was inconclusive or abnormal. The second-line testing provided for in item 66839 will support testing of methylmalonic acid and homocysteine, which are specific tests for vitamins B12 deficiency for uncommon clinical conditions. This amendment will also implement an 11 month frequency restriction to item 66839 to align the item with amendments being made to the first-line testing item 66838 (see item 86). 

Item 88 inserts new item 66842 into the PST for quantification of one or more of total vitamin B12, holotranscobalamin, methylmalonic acid or homocysteine. Item 66842 is intended to provide an exception from the frequency limitation in items 66838 and 66839 for patients with a clinical need. This item is intended to be used for two patient cohorts:

• patients that are still experiencing symptoms of vitamin B12 deficiency 3 to 6 months after a service described in item 66838 or item 66839 was rendered, or that obtained inconclusive results from a service described in item 66839; and
• patients that have risk factors for abnormal vitamin B12 levels (i.e. low dietary intake, family history, previous abdominal or pelvic radiotherapy, previous gastrointestinal tract surgery, recreational nitrous oxide use or recent history of use, clinical conditions with a risk of B12 deficiency, requiring monitoring of vitamin B12 treatment, or use of vitamin B12-antagonistic medicines).

Item 89 repeals and substitutes the cell at column 2 for item 69333, which describes a service for urine examination, to reduce unnecessary patient testing. This item will limit the service to patients with symptoms of urinary tract infection or kidney disease, or particular cohorts of higher risk asymptomatic patients where it is clinically appropriate to test. This item provides that “clinically-indicated asymptomatic patients” are patients that are:

• pregnant;
• less than 16 years of age;
• recipients of renal transplants;
• suffering from recurrent urinary tract infections;
• being investigated or monitored for kidney disease; and/or
• undergoing urinary tract instrumentation, urological procedures or transurethral resection of the prostate.

Part 4—Other amendments

Health Insurance Regulations 2018 (HIR)

Items 90 and 91 amend column 2 of table item 9 and table item 18 in subsection 28(1) of the HIR, respectively, to add reference to two new MBS items 695 and 19000 for health assessments for women experiencing menopause or perimenopause. New items 695 and 19000 will be introduced to the MBS on 1 July 2025 by way of a determination made under section 3C of the Act. New item 695 will be added to Group A14 and new item 19000 will be added to Subgroup 5 of Group A7. Both items will be available for an initial period of two years.

Items 90 and 91 will add new items 695 and 19000 to column 2 of the table at subsection 28(1) of the HIR to provide that these new items are subject to a 100% benefit rate, as these services will be delivered by general practitioners and prescribed medical practitioners within general practice.

Item 92 amends section 44 of the HIR to add a new row 1A to the table for “R-type diagnostic imaging service—request by participating nurse practitioner”, which sets out services that nurse practitioners can request on behalf of a medical practitioner under subsections 16B(1) and 16B(3E) of the Act. This new row 1A includes, in column 2, reference to two new items 57410 and 57413 (which is specified as Group I2 services in column 1 of the table) for low-dose computed tomography scans which can be requested by a medical practitioner or nurse practitioner. New items 57410 and 57413 will be introduced to the MBS on 1 July 2025 by way of a determination under section 3C of the Act, pursuant to the National Lung Cancer Screening Program.

Statement of Compatibility with Human Rights

Prepared in accordance with Part 3 of the Human Rights (Parliamentary Scrutiny) Act 2011

Health Insurance Legislation Amendment (2025 Measures No. 2) Regulations 2025

This Regulation is compatible with the human rights and freedoms recognised or declared in the international instruments listed in section 3 of the Human Rights (Parliamentary Scrutiny) Act 2011.

Overview of the Disallowable Legislative Instrument

The purpose of the Health Insurance Legislation Amendment (2025 Measures No. 2) Regulations 2025 (the Regulations) will amend the DIST, GMST and PST immediately after the commencement of the Health Insurance Legislation Amendment (Indexation) Regulations 2025 on 1 July 2025. The Regulations will introduce and amend MBS items as agreed to in the 2024-25 Budget, the 2023-24 Mid-Year Economic and Fiscal Outlook (MYEFO) and the 2023-24 Budget. Additionally, the Regulations will implement administrative and machinery changes to the DIST and the GMST.

The Regulations will:

• amend two whole body fluorodeoxyglucose (FDG) positron emission tomography (PET) study items to remove the definition of rare or uncommon cancer;
• change the eligibility requirements for diagnostic imaging equipment;
• make consequential changes to the DIST to remove a reference to the Royal Australian and New Zealand College of Radiologists (RANZCR) Quality and Accreditation Program and remove an item from a maximum claiming limit;
• amend a urine examination pathology test to restrict testing to symptomatic and some asymptomatic patients to reduce clinically unnecessary testing;
• amend two vitamin B12 pathology tests and list a new vitamin B12 pathology item for more frequent testing to clarify the appropriate testing pathway of vitamin B12;
• introduce new and amend existing MBS items for ophthalmology services as recommended by the MBS Review Taskforce or Medical Services Advisory Committee (MSAC);
• make consequential changes to items 104 and 105 as a result of two new gynaecology long consultation items (items 125 and 126) for patients with complex conditions;
• make consequential changes to items 132 and 133 as a result of new and amended changes to specialist and consultant physicians telehealth items;
• add a co-claiming restriction to item 92614 for telehealth attendance by a specialist in the practice of neurosurgery;
• make an administrative amendment to change the definition of ‘Telehealth and Telephone Determination’;
• insert items 125 and 126 into Group A3 of the GMST to provide gynaecology long consultation items for patients with complex conditions; and
• amend ten radiation oncology items for megavoltage treatment to clarify how often the items can be claimed, to update referenced item numbers, and to make further minor corrections in line with original policy intent.

Human rights implications

The Regulations engage Articles 9 and 12 of the International Covenant on Economic Social and Cultural Rights (ICESCR), specifically the rights to health and social security.

The Right to Health

The right to the enjoyment of the highest attainable standard of physical and mental health is contained in Article 12(1) of the ICESCR. The UN Committee on Economic Social and Cultural Rights (the Committee) has stated that the right to health is not a right for each individual to be healthy, but is a right to a system of health protection which provides equality of opportunity for people to enjoy the highest attainable level of health.

The Committee reports that the ‘highest attainable standard of health’ takes into account the country’s available resources. This right may be understood as a right of access to a variety of public health and health care facilities, goods, services, programs, and conditions necessary for the realisation of the highest attainable standard of health.

The Right to Social Security

The right to social security is contained in Article 9 of the ICESCR. It requires that a country must, within its maximum available resources, ensure access to a social security scheme that provides a minimum essential level of benefits to all individuals and families that will enable them to acquire at least essential health care. Countries are obliged to demonstrate that every effort has been made to use all resources that are at their disposal in an effort to satisfy, as a matter of priority, this minimum obligation.

The Committee reports that there is a strong presumption that retrogressive measures taken in relation to the right to social security are prohibited under ICESCR. In this context, a retrogressive measure would be one taken without adequate justification that had the effect of reducing existing levels of social security benefits, or of denying benefits to persons or groups previously entitled to them. However, it is legitimate for a Government to re-direct its limited resources in ways that it considers to be more effective at meeting the general health needs of all society, particularly the needs of the more disadvantaged members of society.

The right of equality and non-discrimination

The rights of equality and non-discrimination are contained in articles 2, 16 and 26 of the International Covenant on Civil and Political Rights (ICCPR).  Article 26 of the ICCPR requires that all persons are equal before the law, are entitled without any discrimination to the equal protection of the law and in this respect, the law shall prohibit any discrimination and guarantee to all persons equal and effective protection against discrimination on any ground such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.

Analysis

The Regulations maintain the rights to health and social security and the right of equality and non-discrimination by ensuring access to publicly subsidised medical services that are clinically relevant and cost-effective as intended. The Regulations also advance the rights to health and social security and the right of equality and non‑discrimination by introducing new services which will be available as publicly subsidised medical services.

Conclusion

This instrument is compatible with human rights because it maintains existing arrangements and the protection of human rights.

Mark Butler

Minister for Health and Ageing