EXPLANATORY STATEMENT
HEALTH INSURANCE ACT 1973
SECTION 4BA
Health Insurance (Pathologist-Determinable Services) Amendment Determination 2014 (No. 2)
Section 4BA of the Health Insurance 1973 (the Act) provides that the Minister may, following consultation with the Royal College of Pathologists of Australasia (RCPA), determine that a particular pathology service, or pathology services included in a class of pathology services, are pathologist-determinable services.
The Health Insurance (Pathologist-determinable Services) Amendment Determination 2014 (No. 2) (the Amendment Determination) amends the Health Insurance (Pathologist-determinable Services) Determination 2006 (No. 3) (the Principal Determination) to specify one new pathology service as a pathologist-determinable service.
Section 16A of the Act specifies that certain requirements have to be met for the payment of Medicare benefits in relation to pathology services. Subsections 16A(1), (3) and (6) together provide that a Medicare benefit is not payable in respect of a pathology service unless the service was rendered pursuant to a request or is a pathologist-determinable service.
Determining a service as a pathologist-determinable service obviates the need for a request from a treating practitioner and allows for the payment of Medicare benefits to cover specific circumstances where:
- services are requested and performed by an Approved Pathology Practitioner (APP) for their own patients; or
- services are deemed necessary in the interest of the patient by the APP, in light of results obtained from earlier tests performed in response to a request from the treating practitioner.
An example of the former is a haematologist or immunologist performing pathology services for their own patients. An example of the latter is the receipt of a request by a histopathologist for the examination of a biopsy specimen and following examination the histopathologist determines that further tests are necessary to complete the diagnosis. The histopathologist would be able to undertake further testing without the need to seek another request from the treating practitioner.
From 1 November 2014, a new Medicare pathology item 66839 will be listed on the Health Insurance (Pathology Services Table) Regulation 2014 for the quantification of vitamin B12 markers such as holoTranscobalamin or methylmalonic acid, where initial serum vitamin B12 result (test described in item 66838) is low or equivocal. Where not provided as a pathologist-determinable service, the service described in item 66839 must be requested by a treating practitioner.
The Amendment Determination amends the Principal Determination to allow the service described in item 66839 to be performed as a pathologist-determinable service by, or on behalf of, an APP:
- to a patient of that APP; and
- where the APP considers it to be necessary on the basis of information the APP has learned as a result of providing another pathology service described in item 66838 requested by the patient’s treating practitioner.
The Amendment Determination also makes minor technical amendments to subparagraph 5(b)(iii) of the Principal Determination and the table to that subparagraph to improve clarity of drafting and bring it in line with modern standards. This does not involve a substantive change to the operation of the provision.
Consultation
The RCPA has been consulted concerning the amendment, as required by section 4BA of the Act. The RCPA endorsed enabling the provision of the service described in item 66839 as a pathologist-determinable service.
The Amendment Determination commences on 1 November 2014.
The start date ensures that a Medicare benefit will be payable for the new item when provided as a pathologist-determinable service.
The Amendment Determination is a legislative instrument for the purposes of the Legislative Instruments Act 2003.
Statement of Compatibility with Human Rights
Prepared in accordance with Part 3 of the Human Rights (Parliamentary Scrutiny) Act 2011
Health Insurance (Pathologist-determinable Services) Amendment Determination 2014 (No. 2)
This Legislative Instrument 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 Legislative Instrument
The Health Insurance (Pathologist-determinable Services) Amendment Determination 2014 (No. 2) (the Amendment Determination) amends the Health Insurance (Pathologist-determinable Services) Determination 2006 (No. 3) (the Principal Determination) to specify one new Medicare pathology service (item 66839) as a pathologist-determinable service.
The Health Insurance Act 1973 ordinarily requires that a pathology service must be rendered pursuant to a request for Medicare benefit to be payable for the service.
Determining a service as a pathologist-determinable service obviates the need for a request from a treating practitioner and allows for the payment of Medicare benefits where:
- the service is requested and performed by an Approved Pathology Practitioner (APP) for their own patient; or
- the service is deemed necessary in the interest of the patient by the APP, in light of results obtained from earlier tests performed in response to a request from the treating practitioner.
Human rights implications
This Legislative Instrument positively impacts on the rights to health and social security by enabling patients to receive a Medicare benefit for the services described in item 66839 in an expanded range of settings. In particular, the specification of item 66839 as pathologist-determinable service will ensure that, where an APP considers that the results of a patient’s requested services indicate the need for the tests covered by the item to be performed, the APP can provide the follow-up test as a Medicare-eligible service. It also enables APPs to provide the services to their own patients as a Medicare-eligible service.
There are no patient eligibility criteria such as age or gender that must be met in order for item 66839 to be provided as a pathologist-determinable service.
Conclusion
This Legislative Instrument is compatible with human rights because it impacts positively on the human rights to health and social security and does not limit any of the rights and freedoms recognised or declared in the international instruments listed in section 3 of the Human Rights (Parliamentary Scrutiny) Act 2011.
Kirsty Faichney
Acting First Assistant Secretary
Medical Benefits Division
Department of Health