EXPLANATORY STATEMENT
Select Legislative Instrument 2009 No. 227
Health Insurance Act 1973
Health Insurance (Pathology Services Table) Amendment Regulations 2009 (No. 3)
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.
The Act provides, in part, for payments of Medicare benefits in respect of professional services rendered to eligible persons. Section 9 of the Act provides that Medicare benefits shall be calculated by reference to the fees for medical services, including pathology services, set out in prescribed tables.
Section 4A of the Act provides that the regulations may prescribe a table of pathology services that sets out items of pathology services, the amount of fees applicable in respect of each item, and rules for interpretation of the pathology services table. The Health Insurance (Pathology Services Table) Regulations 2008 currently prescribe such a table.
The purpose of the regulations is to make item 66900 exempt from the coning rule, by adding it to rule 18A. The coning rule is the restriction for which Medicare benefits are paid for pathology services within a single patient episode. This rule applies to out of hospital pathology services requested by general practitioners and limits the benefits payable to only three services with the highest schedule fee. The coning rule applies to all items on the Pathology Services Table unless specified.
Item 66900 was introduced on 1 May 2009 and is a direct mirror of existing item 12533 on the General Medical Services Table, which provides a rebate for a carbon-labelled urea breath test for Helicobacter pylori. Item 66900 was created to solve a Medicare Australia billing issue for pathologists trying to claim this test. Since item 12533 is not included in the episode cone rule, to act as an effective mirror item 66900 needs also to be exempt.
This exemption is to be backdated to 1 May 2009 to ensure continuity of the exemption and to ensure no patients are disadvantaged by limited payment of benefits due to incorrect application of the coning rule.
The retrospective commencement of these regulations does not offend subsection 12(2) of the Legislative Instruments Act 2003. The only possible effect on individuals affected by the amendment is that they may be entitled to a Medicare payment to which they would not be entitled under the regulations before the amendment was made. The amendment made by the regulations therefore does not adversely affect the rights or impose liabilities on any person (other than the Commonwealth or an authority of the Commonwealth).
The descriptor for item 66900 is amended to indicate that it is subject to rule 18.
The Pathology Services Table Committee (PSTC) has discussed the proposal regarding item 66900 at a recent meeting. PSTC members, who include representatives of the Royal College of Pathologists of Australasia, the Australian Association of Pathology Practices and the National Coalition of Public Pathology, agreed on the proposal in the form put forward in the minute. These organisations are the three peak representative bodies for pathology in Australia.
The Act specifies no conditions that need to be satisfied before the power to make the Regulations may be exercised.
The Regulations are a legislative instrument for the purposes of the Legislative Instruments Act 2003.
The Regulations are taken to have commenced on 1 May 2009.
Overview
The Health Insurance (Pathology Services Table) Amendment Regulations 2009 (No. 3) were enacted to address a specific billing issue related to pathology services under the Health Insurance Act 1973. This legislation was introduced to ensure the accurate application of Medicare benefits for out-of-hospital pathology services. The regulations were made under subsection 133(1) of the Act, allowing the Governor-General to prescribe regulations that are necessary for carrying out or giving effect to the Act. The amendment aims to exempt item 66900 from the coning rule, which restricts Medicare benefits for pathology services within a single patient episode to only the three services with the highest schedule fee. This exemption was necessary to mirror the existing item 12533 on the General Medical Services Table, which provides a rebate for a carbon-labelled urea breath test for Helicobacter pylori. The changes are backdated to 1 May 2009 to ensure continuity and prevent any patient disadvantage due to incorrect application of the coning rule.
Scope and Application
The Health Insurance (Pathology Services Table) Amendment Regulations 2009 (No. 3) pertains to the Health Insurance Act 1973, which governs the provision of Medicare benefits for various medical services, including pathology services, to eligible individuals in Australia. This particular amendment regulation focuses on modifying the Pathology Services Table to exempt item 66900 from the coning rule. This exemption ensures that Medicare benefits for pathology services are not restricted to only the three services with the highest schedule fee when these services are requested by general practitioners outside of a hospital setting. The exemption is backdated to 1 May 2009 to maintain continuity and prevent patients from being disadvantaged due to an incorrect application of the coning rule. The regulations do not adversely affect the rights or impose liabilities on any person, except for the Commonwealth or its authorities, and the amendments are retrospective to ensure no individual is unfairly impacted. The Pathology Services Table Committee, which includes representatives from major pathology bodies, has endorsed this amendment, reflecting a consensus among key stakeholders in the pathology sector.
Key Provisions
The Health Insurance (Pathology Services Table) Amendment Regulations 2009 (No. 3) primarily amend the existing Health Insurance (Pathology Services Table) Regulations 2008. The key provision of these regulations is to exempt item 66900 from the coning rule, which restricts Medicare benefits for pathology services within a single patient episode to only three services with the highest schedule fee. This exemption is achieved by adding item 66900 to rule 18A (section 4). This amendment is intended to mirror existing item 12533 on the General Medical Services Table, which provides a rebate for a carbon-labelled urea breath test for Helicobacter pylori, and ensures that pathologists can correctly claim this test without being subject to the coning rule.
The regulations impose specific obligations on the entities governed by them, particularly on the Pathology Services Table Committee (PSTC), which includes representatives from the Royal College of Pathologists of Australasia, the Australian Association of Pathology Practices, and the National Coalition of Public Pathology. These representatives have agreed on the proposal to exempt item 66900 from the coning rule, as discussed in the recent PSTC meeting. The regulations require that the descriptor for item 66900 be amended to indicate that it is subject to rule 18, thus ensuring that the item is exempt from the coning rule.
There are no specific offences, penalties, or civil/criminal consequences outlined for breach of these regulations. However, the retrospective application of these regulations ensures that any affected individuals may be entitled to a Medicare payment they would not have been eligible for under the previous regulations. The purpose of this backdating is to ensure continuity and avoid disadvantaging patients due to incorrect application of the coning rule. Importantly, the amendment does not adversely affect the rights or impose liabilities on any person, other than the Commonwealth or an authority of the Commonwealth. The regulations are a legislative instrument under the Legislative Instruments Act 2003 and are deemed to have commenced on 1 May 2009.