EXPLANATORY STATEMENT

Select Legislative Instrument No. 195, 2014

Health Insurance Act 1973

Health Insurance Legislation Amendment (Optometric Services and Other Measures) Regulation 2014

Subsection 133(1) of the Health Insurance Act 1973 (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.

Subsections 4(1) and 4AA(1) of the Act provides that the regulations may prescribe a table of medical and diagnostic imaging services which set out items of medical and diagnostic imaging services, the fees applicable for each item, and rules for interpreting the table.  The Health Insurance (General Medical Services Table) Regulation 2014 (GMST) and the Health Insurance (Diagnostic Imaging Services Table) Regulation 2014 (DIST) currently prescribe such tables. The Health Insurance Regulations 1975 (HI Regulations) prescribe other ‘matters’ which the Governor-General may make regulations for in accordance with subsection 133(1) of the Act.

The Health Insurance Legislation Amendment (Optometric Services and Other Measures) Regulation 2014 (the Regulation) will amend the GMST, DIST and HI Regulations to implement 2014-15 Budget measures and otherwise ensure that the medical and diagnostic services funded through the Medicare Benefits Schedule (MBS) continue to be up-to-date, representative of best practice medical practice, and reflective of government commitments.

Part 1

Part 1 of the Regulation implements the 2014-15 Budget measures – ‘Medicare Benefits Schedule - Reduced optometry rebates and removal of charging cap’ and ‘Medicare Benefits Schedule - Comprehensive eye examinations’ which are to take effect on 1 January 2015

Part 1 of the Regulation includes the following changes to the GMST that will take effect on 1 January 2015:

-       the MBS fees for optometry services will be reduced by 5.88 per cent, reducing the MBS rebate for these services by 5 per cent;

-       subclause 2.28.4(2) of Schedule 1 will be repealed to remove the charging cap that currently applies to optometrists accessing the Medicare Benefits Schedule, enabling them to set their own fees in a similar manner to other health providers;

-       the period between claiming Medicare rebateable comprehensive eye examinations will be extended from two years to three years for asymptomatic people aged under 65 years; and

-       the period between claiming Medicare rebateable comprehensive eye examination will be reduced from two years to one year for asymptomatic patients aged 65 years and over.

Part 2

Part 2 of the Regulation amends the DIST to clarify the restrictions applied to cone beam computed tomography items 57362 and 57363. These items were inserted in the DIST on 1 November 2014, along with clause 2.2.6 which sets out the restrictions to be applied to these items.

The Regulation amends clause 2.2.6 of the DIST to ensure unnecessary inclusions in paragraph (b) and (c) of clause 2.2.6 will be deleted. The reasons being that;

-          the requirement in paragraph (b) is already covered by section 16EA of the Act which requires equipment for Medicare rebated diagnostic imaging services to be provided by practices which are accredited under a diagnostic imaging accreditation scheme; and

-          the requirement in paragraph (c) is already covered by regulation 10(1)(c) which restricts requests for certain diagnostic imaging services to dental specialists.

As a consequence of removing paragraph (c) from clause 2.2.6; the definition of ‘dental specialists’ will also be removed from Part 3 of Schedule 1 of the DIST.

Part 2 of the Regulation also amends the HI Regulations to clarify that items 57362 and 57363 can also be requested by prosthodontists, and oral medicine specialist or oral pathology specialists, by inserting these items in 10(1)(b) and (d) of the HI Regulations.

Consultation

The Department of Health has consulted with the Department of Human Services and Optometry Australia.

Details of the regulation are set out in the Attachment.

The Act specifies no conditions which need to be met before the power to make the regulation may be exercised. 

The regulation is a legislative instrument for the purposes of the Legislative Instruments Act 2003. 

Part 1 of the Regulation commences on 1 January 2015.

Part 2 of the Regulation commences on the day after registration on the Federal Register of Legislative Instruments.

 Authority:     Subsection 133(1) of the

                                                                                                Health Insurance Act 1973 

ATTACHMENT

Details of the Health Insurance Legislation Amendment (Optometric Services and Other Measures) Regulation 2014

Section 1 – Name

This section provides for the regulation to be referred to as the Health Insurance Legislation Amendment (Optometric Services and Other Measures) Regulation 2014.

Section 2 – Commencement

This section provides for Part 1 of the regulation to commence on 1 January 2015 and Sections 1 to 4 and Part 2 of the regulation to commence on the day after registration of the instrument on the Federal Register of Legislative Instruments.

Section 3 – Authority

This section provides that the regulation is made under the Health Insurance Act 1973.

Section 4 – Schedules

This section provides that each instrument specified in a Schedule to the instrument is amended or repealed as set out in the applicable items in the Schedule concerned.

Schedule 1 – Amendments

Part 1 – Optometric services

Health Insurance (General Medical Service Table) Regulation 2014

Item [1] – Subclause 1.2.3(1) of Schedule 1

This item omits item 10900, which will be repealed under Item 8 of the regulation, from subclause 1.2.3(1) of Schedule 1 and substitutes it with item 10905.

Item [2] – Clause 2.28.1 of Schedule 1 (heading)

Item 2 repeals the heading of Clause 2.28.1 of Schedule 1 and replaces it with a new heading to remove reference to item 10900.

Item [3] – Subclause 2.28.1(1) of Schedule 1

This item repeals subclause 2.28.1(1) of Schedule 1 which relates to the application of item 10900.

Item [4] – Subclause 2.28.4(2) of Schedule 1

Item 4 repeals subclause 2.28.4(2) of Schedule 1 to remove the charging cap that currently applies to optometrists.

Item [5] – After clause 2.28.5 of Schedule 1

Item 5 inserts a new subclause 2.28.6 Meaning of old item 10900 in the items in Group A10.  The meaning of old item 10900 is defined as “item 10900 of the table as it was in force at any time before its repeal by Part 1 of Schedule 1 to the Health Insurance Legislation Amendment (Optometric Services and Other Measures) Regulation 2014.”

This ensures that although item 10900 will be repealed on 1 January 2015, the limitations on claiming within relevant timeframes will continue to apply where necessary to other items within Group A10 that currently make reference to item 10900.

Item [6] – Schedule 1 (item 10900)

Item 6 repeals item 10900 from Schedule 1

Item [7] – Schedule 1 (cell at item 10905, column headed “Fee ($)”)

Item 7 repeals the fee for item 10905 and substitute the new fee of $66.80.

Item [8] – Schedule 1 (items 10907 to 10914)

Item 8 repeals items 10907 to 10914 and substitutes new items 10907 to 10914.

Item 8 effectively splits item 10900 into two items (10910 and 10911) to better articulate the clinical conditions to which the service applies.

New items 10907, 10910 and 10911 extend the period between claiming eye examinations from 24 months to 36 months for asymptomatic people aged under 65 years, and reduce the period from 24 months to 12 months for asymptomatic patients aged 65 years and over.

New item 10907 applies to a comprehensive optometric assessment, being the first in a course of attention, if, within the previous 36 months for a patient who is less than 65 years of age, or within the previous 12 months for a patient who is at least 65 years of age, the patient has attended another optometrist for an attendance to which items 10907, 10910, 10911, 10912, 10913, 10914, 10915 or old item 10900 applied.

New item 10910 applies to a comprehensive optometric assessment, being the first in a course of attention, if the patient is less than 65 years of age and has not within the previous 36 months received a service to which item10907, 10910, 10912, 10913, 10914, 10915 or old item 10900 applied.

New item 10911 applies to a comprehensive optometric assessment, being the first in a course of attention, if the patient is more than 65 years of age and has not within the previous 12 months received a service to which item10907, 10910, 10911, 10912, 10913, 10914, 10915 or old item 10900 applied.

New items 10912, 10913 and 10914 apply to comprehensive optometric reassessments, being the first in a course of attention, where clinical indications such as a significant change of visual function, new signs or symptoms unrelated to an earlier course of attention, or a progressive disorder (excluding presbyopia), require a comprehensive reassessment, within 36 months for people aged under 65 years or within 12 months for patients aged 65 years and over, of an initial consultation to which item 10907, 10910, 10911, 10912, 10913, 10914, 10915 or old item 10900 applied.

Item 8 also repeals the fees for items 10907 to 10914 and substitutes new fees.

Item [9] – Schedule 1 (cell at item 10915, column headed “Fee ($)”)

Item 9 repeals the fee for item 10915 and substitutes the new fee of $66.80.

Item [10] – Schedule 1 (cell at items 10916 and 10918, column headed “Fee ($)”)

Item 10 repeals the fees for items 10916 and 10918 and substitutes new fees.

Item [11] – Schedule 1 (items 10921 to 10929)

Item 11 repeals items 10921 to 10929 and substitutes new items 10921 to 10929.

New items 10921 to 10929 remove item 10900 from the item descriptors and substitute it with “old item 10900” (as defined in new subclause 2.28.6) and new items 10910, 10911.

Item 11 also repeals the fees for items 10921 to 10929 and substitutes new fees.

Item [12] – Schedule 1 (cell at item 10930, column headed “Fee ($)”)

Item 12 repeals the fee for item 10930 and substitutes the new fee of $165.80.

Item [13] – Schedule 1 (cell at item 10931, column headed “Fee ($)”)

Item 13 repeals the fee for item 10931 and substitutes the new fee of $23.30.

Item [14] – Schedule 1 (cell at item 10932, column headed “Fee ($)”)

Item 14 repeals the fee for items 10932 and substitutes the new fee of $11.60. 

Item [15] – Schedule 1 (cell at item 10933, column headed “Fee ($)”)

Item 15 repeals the fee for item 10933 and substitutes the new fee of $7.70.

Item [16] – Schedule 1 (cell at item 10940, column headed “Fee ($)”)

Item 16 repeals the fee for item 10940 and substitutes the new fee of $63.75.

Item [17] – Schedule 1 (cell at item 10941, column headed “Fee ($)”)

Item 17 repeals the fee for item 10941 and substitutes the new fee of $38.45.

Item [18] – Schedule 1 (cell at item 10942 and 10943, column headed “Fee ($)”)

Item 12 repeals the fees for items 10942 and 10943 and substitutes new fees of $33.45.

Part 2 – Other amendments

Health Insurance (Diagnostic Imaging Services Table) Regulation 2014

Item [19] – Clause 2.2.6 of Schedule 1

Item 19 repeals clause 2.2.6 of Schedule 1 of the DIST and substitutes new clause 2.2.6 to clarify the restrictions applied to cone beam computed tomography items 57362 and 57363. Paragraph (b) and (c) of clause 2.2.6 are deleted.

Item [20] – Part 3 of Schedule 1 (definition of dental specialist)

Item 20 repeals the definition of ‘dental specialists’ from Part 3 of Schedule 1 of the DIST.

Health Insurance Regulations 1975

Item [21] – Paragraph 10(1)(b)

Item 21 inserts items “57362, 57363” after item “56068”.

Item [22] – Paragraph 10(1)(d)

Item 22  inserts items “57362, 57363” after item “57345”.