Health Insurance (Medicare Benefits Payable in Respect of Professional Services – Commonwealth Medicare Urgent Care Clinic Program – New South Wales Urgent Care Services) Direction (No. 2) 2025

Overview

The Health Insurance (Medicare Benefits Payable in Respect of Professional Services – Commonwealth Medicare Urgent Care Clinic Program – New South Wales Urgent Care Services) Direction (No. 2) 2025 was enacted to facilitate the payment of Medicare Benefits for professional services provided under the Commonwealth Medicare Urgent Care Clinic Program in New South Wales. This Direction was issued under the authority of the Health Insurance Act 1973 by Nigel Murray, an Assistant Secretary of the Department of Health, Disability and Ageing, acting on behalf of the Minister for Health and Ageing. The primary objective of this Direction is to ensure that Medicare Benefits are payable for professional services that meet the specific criteria outlined, including those provided by authorised practitioners at designated practice locations. This Direction repeals the previous Direction (No. 1) 2025 and introduces new provisions that specify the services, locations, and practitioners eligible for Medicare Benefits payments within the framework of the Commonwealth Urgent Care Clinic program. This legislative instrument aims to address gaps in urgent care services by providing clarity and specificity regarding the services eligible for Medicare Benefits, the locations where these services can be provided, and the types of practitioners authorised to deliver these services. The Direction specifies the professional services that attract Medicare Benefits, such as general practitioner attendances, prescribed medical practitioner services, and other related services, provided they meet the criteria set forth in the Direction. Additionally, the Direction outlines the approved practice locations, which are classified under Modified Monash Model (MMM) 1 and MMM 2-7 categories, and specifies the types of practitioners, including general practitioners, prescribed medical practitioners, and participating nurse practitioners, who are authorised to provide these services. The Direction also includes detailed schedules listing the specific Medicare Benefits Schedule items applicable to the services provided under this program.

Scope and Application

This Direction applies to medical services provided under the Commonwealth Medicare Urgent Care Clinic Program in New South Wales, specifically those services that meet the criteria set out in the agreement between the Commonwealth (Department of Health, Disability and Ageing) and the New South Wales State Government (New South Wales Department of Health). The services in question must be provided by registered practitioners to eligible patients at approved practice locations, as outlined in the schedules to this Direction. The Direction specifies the types of professional services for which Medicare benefits will be payable, including those listed in Schedules A, B, and C of the Direction, and the corresponding items in the general medical services table, pathology service table, and diagnostic imaging table. The Direction applies to services provided to eligible persons who are not receiving a service that attracts a payment under the National Health Reform Agreement for a service rendered to a public patient. The Direction is effective from 1 November 2025 until 30 June 2026 unless earlier revoked. The Direction does not specify any exclusions or exemptions, but it does refer to the definitions provided in the Health Insurance Act 1973 and related regulations. The Direction may be extended or modified by subordinate instruments, although none are currently in place.

Key Provisions

The primary operative sections of the Health Insurance (Medicare Benefits Payable in Respect of Professional Services – Commonwealth Medicare Urgent Care Clinic Program – New South Wales Urgent Care Services) Direction (No. 2) 2025 establish the terms under which Medicare benefits are payable for specific professional services provided by New South Wales Urgent Care Services assessed as meeting the requirements of the Commonwealth Urgent Care Clinic program. Specifically, the Direction outlines the types of professional services eligible for Medicare benefits and the conditions under which these services must be provided. For example, professional services must be provided to an eligible person and cannot be services that attract payments through Schedule K of the 2020-2025 Addendum to the National Health Reform Agreement for public patients. The services must also be provided at approved practice locations and by registered practitioners, such as general practitioners, prescribed medical practitioners, or participating nurse practitioners. The Direction imposes several obligations on the parties involved. Firstly, it mandates that the professional services must be provided by practitioners registered with Services Australia under the Commonwealth Urgent Care Clinic program. These practitioners must also adhere to the specific locations and conditions outlined in the Direction for the services they provide. Secondly, the Direction stipulates that the services must be rendered to eligible persons who are not receiving services that attract payments under Schedule K of the 2020-2025 Addendum to the National Health Reform Agreement for public patients. Lastly, the Direction sets forth the specific items listed in Schedules A, B, and C that are eligible for Medicare benefits. Breaches of the provisions outlined in the Direction may lead to various consequences. Although the Direction itself does not explicitly state penalties, the Health Insurance Act 1973 and associated regulations provide for potential civil and criminal penalties for non-compliance. For instance, fraudulent claims or misrepresentations could result in fines or imprisonment, as stipulated in the Health Insurance Act. Furthermore, practitioners or entities found in breach of the Act's provisions may also face penalties under related legislation, such as the National Health Act 1953, which could include fines or other sanctions. The exact penalties would depend on the nature and severity of the breach, as well as any applicable jurisdictional laws.