AUSTRALIAN GOVERNMENT
DEPARTMENT OF HEALTH AND AGED CARE
HEALTH INSURANCE ACT 1973
Health Insurance (Medicare Benefits Payable in Respect of Professional Services – Services Rendered under the Commonwealth Urgent Care Clinic Program) Direction 2023
I, Daniel McCabe, First Assistant Secretary, Medicare Benefits and Digital Health Division, Health Resourcing Group, delegate for the Minister for Health and Aged Care, acting under subsection 19(2) of the Health Insurance Act 1973, hereby:
- DIRECT that Medicare Benefits shall be payable in respect of:
(a) A professional service (as defined in Section 3 of the Health Insurance Act 1973) which has been agreed to be provided under the Commonwealth Medicare Urgent Care Clinic Program between the Department of Health and Aged Care (ABN: 83 605 426 759) and the practices listed in Schedule B of this direction in relation to medical services available to patients who attend a Commonwealth Urgent Care Clinic Location for which;
(i) items specified in Schedule A of this Direction; and of the general medical services table (means the table prescribed under subsection 4(1) of the Health Insurance Act 1973) relates: and
(b) Where the professional service is provided to:
(i) an eligible person (as defined in Section 3 of the Health Insurance Act 1973);
(ii) a patient who is not receiving the service as part of an episode of hospital treatment (as defined in Section 121-5 of the Private Health Insurance Act 2007);
(iii) a patient who also is not receiving a service:
- which attracts a payment through the 2020-2025 Addendum to the National Health Reform Agreement for a service rendered to a public patient; or
- which attracts a payment through another government arrangement outside of the Commonwealth Medicare Urgent Care Clinic program for a service rendered to the patient; and
(c) the professional services referred to in clause (a) must be provided:
(i) at a general practice (as defined in Section 7.1.1 of the general medical services table); and
(ii) by a general practitioner or participating nurse practitioner mentioned in (a) who is registered to provide services, in Schedule A, with Services Australia under the Commonwealth Urgent Care Clinic program.
DECLARE that this Direction shall have effect from 30 June 2023 until 30 June 2026 inclusive unless earlier revoked.
Date this 15 day of June 2023
Daniel McCabe
First Assistant Secretary
Medicare Benefits and Digital Health Division
Health Resourcing Group
Department of Health and Aged Care
SCHEDULE A
MEDICARE BENEFITS SCHEDULE ITEMS AS AGREED under the Urgent care clinic program
For services listed in the below tables, all provisions of the Health Insurance Act 1973 (the Act) and regulations made under the Act, and the National Health Act 1953 and regulations made under the National Health Act 1953, relating to medical services, professional services or items apply.
General Medical Services Table
Group | Group Name | Subgroup | Subgroup Name | Item Number |
A1 | GP attendances to which no other item applies | 1 | Level A | 3 |
2 | Level B | 23 |
3 | Level C | 36 |
4 | Level D | 44 |
A5 | Prolonged Attendance to Which no Other Item Applies | 1 | Prolonged Professional Attendance |
A20 | GP Mental health Care | 1 | GP Mental Health Treatment Plans | 2713 |
A22 | General Practitioner After-Hours Attendances To Which No Other Item Applies | 1 | Level A | 5000 |
2 | Level B | 5020 |
3 | Level C | 5040 |
4 | Level D | 5060 |
T4 | Obstetrics | 16500 |
T7 | Regional or Field Nerve Blocks | 18213 |
T8 | Surgical Operations | 1 | General | 30003, 30006, 30026, 30029, 30032, 30035, 30038, 30042, 30045, 30049, 30061, 30064, 30099, 30216, 30219 |
2 | Colorectal | 32147 |
5 | Urological | 36800 |
8 | Ear, Nose and Throat | 41500, 41677 |
9 | Ophthalmology | 42644, 42650 |
14 | Hand Surgery | 46513, 46528, 46531 |
15 | Orthopaedic | 47904, 47915, 47916, 47015, 47030, 47042, 47057, 47063, 47069, 47301, 47348, 47354, 47361, 47387, 47423, 47444, 47453, 47462, 47466, 47471, 47543, 47561, 47579, 47595, 47637, 47663, 47735 |
M1 | Management of Bulk Billed Services | | | 10990, 10991, 10992, 75855, 75856, 75857, 75858 |
M14 | Nurse Practitioners | 1 | Nurse Practitioners | 82200, 82205, 82210, 82215 |
SCHEDULE B
Approved COMMONWEALTH Urgent care clinic Locations AS AGREED under the Commonwealth urgent care clinic program
Approved primary care locations:
State | Location/ Town | Practice Name | Legal Name | Street Address |
WA | Perth City | Rudloc Road Medical and Dental Centre | Rudloc Road Medical and Dental Centre | 40 Rudloc Rd, Morley WA 6062 |
WA | Rockingham | Rockingham Medical and Dental Centre | Rockingham Medical and Dental Centre | 18 Civic Blvd, Rockingham WA 6168 |
WA | Joondalup | Fair First Pty Ltd, Trading as Ocean Keys Family Practice | The Trustee for OKM Trust. | Unit 6/5 Ebb Way,
Clarkson WA 6030 |
Overview
The Health Insurance (Medicare Benefits Payable in Respect of Professional Services – Services Rendered under the Commonwealth Urgent Care Clinic Program) Direction 2023 (the Direction) was enacted by the Australian Government Department of Health and Aged Care. This Direction addresses the need to ensure that Medicare benefits are payable for services rendered under the Commonwealth Urgent Care Clinic Program, thereby providing eligible patients with necessary healthcare services. Enacted under the authority of the Health Insurance Act 1973, the policy objective of this Direction is to facilitate the provision of professional medical services in urgent care clinics to eligible patients, ensuring that these services are compensated appropriately through Medicare. This initiative aims to enhance access to urgent medical care and support general practitioners and nurse practitioners involved in delivering such services. The Direction is effective from 30 June 2023 until 30 June 2026 unless earlier revoked.
Scope and Application
The Health Insurance (Medicare Benefits Payable in Respect of Professional Services – Services Rendered under the Commonwealth Urgent Care Clinic Program) Direction 2023 applies to medical services provided under the Commonwealth Urgent Care Clinic Program. It specifies the payment of Medicare benefits for professional services rendered by general practitioners or participating nurse practitioners who are registered with Services Australia to provide these services. The Direction applies to eligible patients attending approved urgent care clinics in locations listed in Schedule B of the Direction. The geographic reach of the Direction is nationwide, as it involves clinics that are part of the Commonwealth program. The Direction excludes services provided to patients receiving hospital treatment, those receiving payments through other government arrangements outside of the urgent care clinic program, or those receiving services as part of an episode of hospital treatment. The Direction also specifies that the payment of benefits is applicable to the Medicare benefits schedule items listed in Schedule A, which includes a range of general medical services and surgical operations. This Direction is effective from 30 June 2023 until 30 June 2026, unless earlier revoked, and it extends the application of the Health Insurance Act 1973 and related regulations to these specific services and locations.
Key Provisions
The main operative sections of this Direction, issued under the Health Insurance Act 1973, pertain to the payment of Medicare Benefits for professional services rendered under the Commonwealth Urgent Care Clinic Program (Section 1). The Direction specifies the professional services eligible for Medicare benefits, the conditions under which these services can be provided, and the entities involved in delivering these services (Section 2). According to this Direction, Medicare benefits will be payable for professional services agreed to be provided under the Commonwealth Urgent Care Clinic Program, which are detailed in Schedule A of this Direction and listed in the general medical services table (Section 2(a)). These services must be provided to eligible persons who are not receiving the service as part of an episode of hospital treatment or as part of another government payment arrangement (Section 2(b)). The services must be provided at a general practice by registered general practitioners or participating nurse practitioners (Section 2(c)).
The Direction imposes several obligations on the parties involved. The Department of Health and Aged Care must ensure that the services listed in Schedule A are provided under the Commonwealth Urgent Care Clinic Program by the approved practices detailed in Schedule B. General practitioners and nurse practitioners must be registered with Services Australia to provide these services. Practices listed in Schedule B must adhere to the terms and conditions of the agreement with the Department of Health and Aged Care, ensuring that the services are provided to eligible patients in accordance with the requirements set out in the Direction (Section 2).
Breaches of the provisions outlined in this Direction may result in civil or criminal consequences, depending on the nature and severity of the breach. While specific penalties are not detailed in the Direction itself, violations of the Health Insurance Act 1973 or related regulations may lead to penalties under the Act, which can include fines and other sanctions. The penalties for breaches of the Act can be substantial, reflecting the seriousness of non-compliance with health insurance provisions. For example, under the Health Insurance Act 1973, penalties for making false claims can include fines up to $22,200 for individuals and $111,000 for corporations, with additional penalties for repeated offences. These penalties underscore the importance of compliance with the provisions of the Direction and the broader legislative framework governing health insurance in Australia.