Health Insurance (Positron Emission Tomography) Facilities Determination 2009 (No. 2)

Overview

The Health Insurance (Positron Emission Tomography) Facilities Determination 2009 (No. 2) was enacted to address the need for updated provisions concerning the provision and reimbursement of positron emission tomography (PET) services under the Health Insurance Act 1973. This legislation, issued by the Minister for Health and Ageing, serves to ensure that PET services are adequately recognised and remunerated within the Medicare framework. The Determination was necessary to incorporate changes to the current Determination in order to give effect to the new rule 28 of the Health Insurance (Diagnostic Imaging Services Table) Regulations 2009, which allows for an increased Medicare rebate for certain diagnostic imaging services provided out of hospital and bulk-billed. The policy objective of the Determination is to ensure that PET services are appropriately classified and compensated under the Act, thereby enhancing access to these essential medical services for patients. The Determination, which commenced on 1 November 2009, revokes the previous Health Insurance (Positron Emission Tomography) Facilities Determination 2009 and incorporates changes to reflect the new regulatory framework. The changes were developed through internal-to-government budget processes and informed by extensive consultation with key stakeholders, including professional medical associations, as part of a broader review of pathology and diagnostic imaging services. This legislative instrument aims to streamline the reimbursement process for PET services, ensuring they are listed appropriately in the diagnostic imaging services table and are compensated in line with the updated fee structure.

Scope and Application

The Health Insurance (Positron Emission Tomography) Facilities Determination 2009 (No. 2) applies to services rendered by facilities that perform Positron Emission Tomography (PET) services under a written agreement with the Commonwealth and upon a written request from a specialist or consultant physician. This Determination ensures that such services are treated as professional and medical services for the purposes of the Health Insurance Act 1973 and related regulations. The application of this Determination is contingent on the existence of a formal agreement with the Commonwealth and the requisite physician’s request, thereby defining the scope of its jurisdictional reach. This legislation, which comes into effect on 1 November 2009, revokes its predecessor, the Health Insurance (Positron Emission Tomography) Facilities Determination 2009, to incorporate new provisions and updates as outlined in rule 28 of the Health Insurance (Diagnostic Imaging Services Table) Regulations 2009, which pertain to Medicare rebates for out-of-hospital diagnostic imaging services that are bulk-billed.

Key Provisions

The Health Insurance (Positron Emission Tomography) Facilities Determination 2009 (No. 2) (the Determination) is a legislative instrument that updates the previous determination to align with new rule 28 of the Health Insurance (Diagnostic Imaging Services Table) Regulations 2009 (the DIST Regulations). This new rule pertains to a Medicare rebate increase for certain diagnostic imaging services provided outside of hospitals, specifically those that are bulk-billed. Section 6(a) of the Determination states that the relevant positron emission tomography (PET) services specified in the Schedule are treated as both professional and medical services under the Health Insurance Act 1973 (the Act), the National Health Act 1953 and the National Health Regulations 1954. Additionally, Section 6(b) specifies that these services are treated as if they were R-type diagnostic imaging services in the diagnostic imaging services table with a specified fee. The Determination imposes specific obligations on the parties involved, primarily the owner or operator of the PET facility and the specialist or consultant physician. Section 5 sets out the circumstances under which the Determination applies. These include the requirement for a written agreement between the PET facility and the Commonwealth, and a written request from a specialist or consultant physician stating that the service was necessary and that the patient is under their care. This ensures that the services are rendered under appropriate conditions and that the Commonwealth's interests are protected. In terms of consequences for non-compliance, the Determination itself does not explicitly outline specific penalties or offences. However, the overarching legislation, the Health Insurance Act 1973, may impose penalties for non-compliance with its provisions. For example, unauthorised use of Medicare benefits could lead to civil or criminal penalties under the Act, with potential fines and imprisonment. The specific penalties would be determined in accordance with the relevant sections of the Act and any subsidiary legislation. In summary, the Health Insurance (Positron Emission Tomography) Facilities Determination 2009 (No. 2) aligns with the new rule 28 of the DIST Regulations, treating specified PET services as professional and medical services with a defined fee. The Determination applies under specific conditions involving written agreements and requests from specialists or consultant physicians. While the Determination does not explicitly state penalties for non-compliance, the broader Health Insurance Act 1973 and related regulations may impose civil or criminal penalties for breaches.