Health Insurance Regulations (Amendment) 1997 No. 395
EXPLANATORY STATEMENT
STATUTORY RULES 1997 No. 395
Issued by authority of the Minister for Health and Family Services
Health Insurance Act 1973
Health Insurance Regulations (Amendment)
The Health Insurance Act 19 73 (the Act) provides in part for the payment of Medicare benefits for professional services rendered by medical practitioners and for certain professional services rendered by dental practitioners and optometrists.
Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.
Section 4AA of the Act provides in part that regulations may prescribe a table of diagnostic imaging services that sets out items of both R-type and NR-type, the amount of fees applicable for each item and rules of interpretation. The Health Insurance (1997-98 Diagnostic Imaging Services Table) Regulations prescribe such a table.
Subsection 16B(1) of the Act provides in part that Medicare benefits are not payable for an R-type diagnostic imaging service rendered by the providing medical practitioner unless the service was requested in writing by another medical practitioner, a dental practitioner, a chiropractor, a physiotherapist or a podiatrist.
Subsection 16B(11) of the Act provides in part that prescribed R-type diagnostic imaging services may be rendered by a medical practitioner without the requirement for a written request from another medical practitioner, a dental practitioner, a chiropractor, a physiotherapist or a podiatrist and the service is rendered prior to a "sunset" date and the rendering medical practitioner meets requirements for an exemption as a preexisting practice.
Sub-paragraph 16B(11)(d) of the Act provides that the "sunset" date is 1 January 1997 or a later date if prescribed by regulation.
Regulation 12A of the Health Insurance Regulations prescribes a date of 1 January 1998 for the purposes of sub-paraggraph 16B(11)(d) of the Act.
The regulations extend by twelve months the "sunset" provision for medical practitioners who meet the preexisting practices requirement giving exemption from the written request requirements for the diagnostic imaging R-type services.
The exemption provision was included in the Act following representations from the Royal Australian College of General Practitioners who were concerned that, unless the needs of some of their members were given special consideration, the proposed requesting arrangements would disadvantage those who had been providing diagnostic imaging services for many-years. Following discussions with the College, it was agreed that an exemption would be provided for medical practitioners who had been providing x-rays for many years on the basis that a "sunset" provision would apply and the College would develop accreditation guidelines. It has taken longer than envisaged to develop the guidelines.
The extension by twelve months of the sunset provision will enable the College to finalise the accreditation guidelines.
For patients, the effect of the proposed regulation will be to preserve benefit entitlements for R-type diagnostic imaging services rendered on and from 1 January 1998 to 31 December 1998 by medical practitioners who otherwise meet the pre-existing practice requirement.
The requirements for an exemption as a pre-existing practice are that: the service was specified in regulations made for this purpose; the service was rendered by or on behalf of the providing practitioner in the course of treating his or her own patient; the providing practitioner determined that the service was necessary; the service was rendered before 1 January 1998; and during the period commencing 17 October 1988 and ending on 16 October 1990, at least 50 services had been rendered by or on behalf of the providing practitioner, each of the services being a service that would have been an R-type diagnostic imaging service if it had been rendered after the commencement of the amendments to the Act that enabled section 16B, was rendered at a location at which the first service was rendered and resulted in the payment of a Medicare benefit.
The regulation amends regulation 12A of the Health Insurance Regulations by omitting the date "1 January 1998" and substituting the date "1 January 1999".
The regulations commence on 1 January 1998.
Overview
The Health Insurance Regulations (Amendment) 1997 No. 395 were introduced to extend the exemption period for certain diagnostic imaging services under the Health Insurance Act 1973. Enacted by authority of the Minister for Health and Family Services, these regulations aim to address the gap in accommodating the needs of medical practitioners who had been providing diagnostic imaging services before the new requirements were introduced. The policy objective is to ensure that these practitioners can continue to provide services without the need for written requests from other medical professionals, while allowing sufficient time for the development of necessary accreditation guidelines by the Royal Australian College of General Practitioners. This amendment extends the exemption period by one year, to 1 January 1999, allowing continued benefit entitlements for specified services provided by these practitioners until the end of 1998.
Scope and Application
The Health Insurance Regulations (Amendment) 1997 No. 395 applies to medical practitioners who meet the criteria of pre-existing practices for providing diagnostic imaging services under the Health Insurance Act 1973. These regulations specifically address the sunset provision that exempts certain medical practitioners from the requirement to obtain a written request from another medical or allied health professional before providing an R-type diagnostic imaging service. The exemption is extended for twelve months, thereby allowing these practitioners to continue providing such services until 31 December 1998. This amendment was made to provide additional time for the Royal Australian College of General Practitioners to develop accreditation guidelines for these exemptions, responding to concerns that the original requirements would disadvantage long-standing practitioners. The regulation modifies the Health Insurance Regulations by extending the exemption date from 1 January 1998 to 1 January 1999, ensuring continuity of benefit entitlements for affected services during this period.
Key Provisions
The Health Insurance Regulations (Amendment) 1997 No. 395, made under the Health Insurance Act 1973 (the Act), introduces amendments to the existing regulations concerning the provision of diagnostic imaging services by medical practitioners, particularly those classified as R-type services. These amendments aim to extend the exemption period for certain medical practitioners from the requirement to obtain a written request from another specified health professional before providing these services. Specifically, the amendment extends the "sunset" date for these exemptions from 1 January 1998 to 1 January 1999, as detailed in regulation 12A (subsection 16B(11)(d) of the Act).
The primary obligation under these regulations is for medical practitioners who meet the specified criteria to ensure that their diagnostic imaging services are provided in accordance with the amended sunset date. For these practitioners, the exemption allows them to provide R-type diagnostic imaging services without a written request from other health professionals if certain conditions are met. These conditions include that the service is specified in the regulations, rendered in the course of treating their own patients, deemed necessary by the practitioner, and rendered before the new sunset date of 1 January 1999. Additionally, practitioners must have rendered at least 50 services meeting these criteria between 17 October 1988 and 16 October 1990, at the same location where the services will continue to be provided.
Failure to comply with the regulations may result in the medical practitioner not being entitled to Medicare benefits for the diagnostic imaging services provided. For instance, if a medical practitioner who does not meet the exemption criteria provides an R-type diagnostic imaging service without a written request, they may not be eligible for payment of Medicare benefits for that service. This lack of entitlement could have significant financial implications for the practitioner, as well as potential administrative or legal consequences if the non-compliance is detected during an audit or review.
The regulations do not explicitly state penalties for non-compliance, but non-compliance with the Health Insurance Act 1973 could result in civil or criminal penalties under other sections of the Act. Civil penalties can include fines, and in severe cases, criminal penalties can include imprisonment, reflecting the seriousness with which non-compliance is treated under Australian law.