EXPLANATORY STATEMENT
Health Insurance Act 1973
Health Insurance (Patient Episode Initiation) Determination 2011 (No.1)
Issued by the Authority of the Minister for Health and Ageing
Authority
Subsection 3C(1) of the Health Insurance Act 1973 (the Act) provides that the Minister may, by writing, determine that a health service not listed in the pathology services table shall, in specified circumstances and for specified statutory provisions, be treated as if it were so listed. The pathology services table is set out in the Health Insurance (Pathology Services Table) Regulations, which are remade each year.
A determination made under subsection 3C(1) of the Act is a legislative instrument (see subsection 3C(4) of the Act and paragraph 6(d) of the Legislative Instruments Act 2003).
Purpose
The purpose of this Determination is to allow for the payment of benefits for the initiation of patient episodes of specified services and incentives for bulk billing of specified episodes where a claim has not already been made. The Determination fixes an oversight, which was the omission of services from the pathology services table.
Background
Three tissue pathology services relating to biopsy complexity levels were listed in the pathology services table; item 72838 commenced on 1 November 2007 (Health Insurance (Pathology Services Table) Regulations 2007), and items 72827 and 72828 commenced on 1 November 2008 (Health Insurance (Pathology Services Table) Regulations 2008). At the time of the respective commencement of those items, benefits were payable for the initiation of patient episodes for services, which were provided in the circumstances specified by the item descriptors in Group P10 of the pathology services table. It was envisaged that these specified circumstances would include, amongst others, circumstances consisting of where a health service listed in items 72838, 72827 or 72828 was provided. It was also envisaged that, from 1 November 2009 onwards, bulk billing incentives would be payable for episodes consisting of the health services described in items 72838, 72827 or 72828 where those items were bulk billed. To facilitate bulk billing incentives, Group P13 was inserted into the pathology services table.
Due to an oversight, no reference was made to items 72838, 72827 or 72828 in either Group P10 or Group P13. Thus the inadvertent effect of the omission was that no benefits were payable for the initiation of patient episodes for the health services described in items 72838, 72827 and 72828 and no bulk billing incentives were payable where those health services were provided under bulk billing arrangements.
In order to correct this oversight the Determination creates new health services, which consist of the initiation of patient episodes of the services described in items 72838, 72827 and 72828 of the pathology services table, to enable benefits to be payable in those circumstances. The Determination also specifies that bulk billing incentives are payable for episodes consisting of the new health services which are created by this Determination.
Commencement
This Determination commences retrospectively from 1 November 2007, which is the same commencement date as the Health Insurance (Pathology Services Table) Regulations 2007. Each of the Schedules in the Determination has a differing commencement date in order to ensure that the relevant benefits and bulk billing incentives commence at the time during which those benefits and bulk billing incentives would have been payable had the pathology services table been made as envisaged. Despite this retrospectivity, payments can only be made for those claims, which are presented after the date that this Determination is registered on the Federal Register of Legislative Instruments.
The retrospectivity of the Determination does not offend subsection 12(2) of the Legislative Instruments Act 2003. Subsection 3C(2) of the Act specifically provides for the making of retrospective determinations under section 3C and the Commonwealth is the only party adversely affected by the retrospective commencement of these provisions of the Determination.
Details of the Determination are set out in the Attachment.
The Act specifies no conditions that need to be satisfied before the power to make the Determination may be exercised.
The Determination is a legislative instrument for the purposes of the Legislative Instruments Act 2003.
Consultation
No consultation was undertaken in the making of the Determination as the Determination corrects consequential oversights; thus it is considered machinery in nature and does not substantially alter existing arrangements.
ATTACHMENT
Details of the Health Insurance (Patient Episode Initiation) Determination 2011 (No.1)
PART 1 PRELIMINARY
Section 1 Name of Determination
This section provides that the name of the Determination is the Health Insurance (Patient Episode Initiation) Determination 2011 (No. 1) (the Determination).
Section 2 Commencement and term
This section provides for differing commencement dates to ensure that the insertion and specification of the new items in the pathology services table coincides with the making of the Health Insurance (Pathology Services Table) Regulations in 2007, 2008 and 2009 when new relevant items were inserted into the table. Part 1 and Schedule 1 commence on 1 November 2007, Schedule 2 commences on 1 November 2008 and Schedule 3 commences on 1 November 2009. Schedule 1 has a term of one year. The remainder of the Determination continues until repealed.
Section 3 Interpretation
Subsection 3(1) defines general terms used in the Determination.
SCHEDULE 1 SPECIFIED HEALTH SERVICES FROM 1 NOVEMBER 2007
Clause 1 Treatment of a relevant service in the table under clause 4 of this Schedule from 1 November 2007
Paragraph 1(a), Schedule 1 of the Determination provides that a health service specified in the table in clause 4, Schedule 1 of the Determination is to be treated as if it were both a professional service and a medical service for the purposes of the provisions of the Act, the National Health Act 1953 and regulations made under each Act which provide for medical services or professional services.
Paragraph 1(b) provides that a health service specified in the table in clause 4, Schedule 1 of the Determination is to be treated as if there were an item in the pathology services table that related to the relevant service and specified a fee for that service, being the fee specified in the table in clause 4 of Schedule 1 in relation to the service.
The treatment is relevant for those specified health services, which were provided during the period of 1 November 2007 to 31 October 2008 inclusive.
Clause 2 Note in relation to Patient Episode Initiation items from 1 November 2007
Clause 2, Schedule 1 of the Determination provides that the note at Group P10 of Part 3 of Schedule 1 of the pathology services table has the effect as if it reads:
“Note Items 73902 to 73908 and 73922 to 73927 in Subgroup 1 apply to the initiation of a patient episode consisting of a service described in a particular item in the table. If the initiation of the patient episode consists of a service described in an item other than those particular services, an item mentioned in Subgroup 2 will apply to the patient episode.”
Clause 3 Specification of items in the pathology services table from 1 November 2007
Clause 3, Schedule 1 of the Determination provides that descriptions in items 73928 to 73929 of the pathology services table should be read as if they specify new items 73902, 73904, 73906, 73908.
This has the effect that, between 1 November 2007 and 31 October 2008 (inclusive), a benefit is not payable for the initiation of a patient episode by collection of a specimen in the circumstances where the specimen is collected in an approved collection centre (whether or not by an approved pathology practitioner of a prescribed laboratory or an employee of an approved pathology authority of a prescribed laboratory) if a benefit is payable for a health service, which is listed in the table in clause 4, Schedule 1 of this Determination.
Clause 4 Table of items
Clause 4, Schedule 1 of the Determination sets out the relevant initiation of patient episode services, assigns applicable item numbers, item descriptors and fees for the services. These items enable the payment of benefits to patients where a health service is provided, which is the initiation of a patient episode consisting of the examination of complexity level 7 biopsy material with multiple tissue blocks from a person who is:
- an in-patient of a hospital (providing the person is not a private patient of either a recognised hospital, or a hospital who receives the service or services from a prescribed laboratory) (73902);
- a private patient of either a recognised hospital, or a hospital who receives the service or services from a prescribed laboratory (73904);
- not a patient of a hospital (providing the initiation of the patient episode is not by a prescribed laboratory) (73906);
- not a patient of a hospital where the initiation of the patient episode is by a prescribed laboratory (73908).
SCHEDULE 2 SPECIFIED HEALTH SERVICES FROM 1 NOVEMBER 2008
Clause 1 Treatment of a relevant service in the table under clause 4 of this Schedule from 1 November 2008
Paragraph 1(a), Schedule 2 of the Determination provides that a health service specified in the table in clause 4, Schedule 2 of the Determination is to be treated as if it were both a professional service and a medical service for the purposes of the provisions of the Act, the National Health Act 1953 and regulations made under each Act which provide for medical services or professional services.
Paragraph 1(b) provides that a health service specified in the table in clause 4, Schedule 2 of the Determination is to be treated as if there were an item in the pathology services table that related to the relevant service and specified a fee for that service, being the fee specified in the table in clause 4 of Schedule 2 in relation to the service.
The treatment is relevant for those specified health services which were provided on and after 1 November 2008.
Clause 2 Note in relation to Patient Episode Initiation items from 1 November 2008
Clause 2, Schedule 2 of the Determination provides that the note at Group P10 of Part 3 of Schedule 1 of the pathology services table has the effect as if it reads:
“Note Items 73914 to 73919 and 73922 to 73927 in Subgroup 1 apply to the initiation of a patient episode consisting of a service described in a particular item in the table. If the initiation of the patient episode consists of a service described in an item other than those particular services, an item mentioned in Subgroup 2 will apply to the patient episode.”
Clause 3 Specification of items in the pathology services table from 1 November 2008
Clause 3, Schedule 2 of the Determination provides that descriptions in items 73928 to 73929 of the pathology services table should be read as if they specify new items 73914, 73916, 73918, 73919.
This has the effect that, on and after 1 November 2008, a benefit is not payable for the initiation of a patient episode by collection of a specimen in the circumstances where the specimen is collected in an approved collection centre (whether or not by an approved pathology practitioner of a prescribed laboratory or an employee of an approved pathology authority of a prescribed laboratory) if a benefit is payable for a health service, which is listed in the table in clause 4, Schedule 2 of this Determination.
Clause 4 Table of items
Clause 4, Schedule 2 of the Determination sets out the relevant initiation of a patient episode services, assigns applicable item numbers, item descriptors and fees for the services. These items enable the payment of benefits to patients where a health service is provided, which is the initiation of a patient episode consisting of the examination of complexity level 4 biopsy material with multiple tissue blocks (12 or more separately identified specimens) or the initiation of a patient episode consisting of the examination of complexity level 7 biopsy material with multiple tissue blocks from a person who is:
- an in-patient of a hospital (providing the person is not a private patient of either a recognised hospital, or a hospital who receives the service or services from a prescribed laboratory) (73914);
- a private patient of either a recognised hospital, or a hospital who receives the service or services from a prescribed laboratory (73916);
- not a patient of a hospital (providing the initiation of the patient episode is not by a prescribed laboratory) (73918);
- not a patient of a hospital where the initiation of the patient episode is by a prescribed laboratory (73919).
SCHEDULE 3 SPECIFICATION OF ITEMS FROM 1 NOVEMBER 2009
Clause 1 Specification of items in the pathology services table from 1 November 2009
Subclause 1(1), Schedule 3 of the Determination provides that item 74994 shall have effect as if item 73914 in the table under clause 4 of Schedule 2, were also specified in the description of item 74994 in the pathology services table. This means that an incentive amount is payable for a patient episode that consists of a pathology service that is bulk billed to which item 73914 applies.
Subclause 1(2), Schedule 3 of the Determination provides that item 74993 shall have effect as if item 73918 in the table under clause 4 of Schedule 2, were also specified in the description of item 74993 in the pathology services table. This means that an incentive amount is payable for a patient episode that consists of a pathology service that is bulk billed to which item 73918 applies.
Subclause 1(3), Schedule 3 of the Determination provides that item 74999 shall have effect as if items 73916 and 73919 in the table under clause 4 of Schedule 2, were also specified in the description of item 74999 in the pathology services table. This means that an incentive amount is payable for a patient episode that consists of a pathology service that is bulk billed to which either item 73916 or 73919 applies.
The note at the end of clause 1 directs attention to subsection 3C(7) of the Act which deems an internal territory to form part of the State of New South Wales.
These provisions take effect on and after 1 November 2009.