EXPLANATORY STATEMENT

Health Insurance Act 1973

Health Insurance (Sacral Nerve Stimulation) Determination HS/07/2006

Issued by the authority of the Minister for Health and Ageing

Background

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 general medical services table (the Table) shall, in specified circumstances and for specified statutory provisions, be treated as if it were so listed.  The Table is set out in the Health Insurance (General Medical Services Table) Regulations 2006 which are remade each year.

A determination made under subsection 3C(1) is a legislative instrument (see subsection 3C(4) of the Act and paragraph 6(d) of the Legislative Instruments Act 2003).

• Health Insurance Determination HS/01/2002

On 12 March 2002, the then Minister for Health and Aged Care made Health Insurance Determination HS/01/2002 (the Current Determination) under subsection 3C(1) of the Act.  The Current Determination permits the payment of Medicare benefit in relation to specified sacral nerve services for the management of refractory urinary continence or urge retention.

Sacral nerve stimulation uses electrical nerve stimulation via a surgically implanted pulse generator and electrodes to improve bladder function. In March 2002, the then Minister for Health and Aged Care endorsed a recommendation by the Medical Services Advisory Committee that funding not be supported for sacral nerve stimulation therapy for patients with refractory urinary incontinence or urge retention. However, limited coverage was agreed by the former Minister in February 2002 for the small number of patients who had had the device implanted under Medicare prior to March 2002 and required ongoing access to procedures to remove or replace the implants. This was effected through the Current Determination.   

The Current Determination provides that the services for sacral nerve stimulation therapy specified in the Schedule to the Current Determination shall be treated as if they were listed in the Table for the purpose of the statutory provisions specified in clause 5 of the Current Determination.  The statutory provisions specified in clause 5 of the Current Determination are those contained in the Act, the National Health Act 1953 and regulations made under each Act which relate to professional and medical services generally.

Subsequent amendments have been made to the Current Determination to increase the fee in respect of the sacral nerve stimulation items specified in the Schedule to the Current Determination to be in line with general fee increases that were being applied to services in the Table (see Health Insurance (Amendment) Determination HS/08/2002, Health Insurance (Amendment) Determination HS/06/2003, Health Insurance (Amendment) Determination HS/10/2004 and Health Insurance (Amendment) Determination HS/04/2005).

• Health Insurance (Sacral Nerve Stimulation) Determination HS/07/2006

Health Insurance (Sacral Nerve Stimulation) Determination HS/07/2006 (the Determination) remakes the Current Determination, as amended.

The Determination revises the wording of various provisions of the Current Determination to reflect updated drafting practice and to clarify the operation of certain provisions. 

In addition, the Determination provides for an increase of 2.1 percent in the fees in respect of the services covered by the Determination compared to the fees for the same services in the Current Determination, as amended.  This fee increase is in line with the general fee increase that is being applied to most services in the Table from 1 November 2006.

Details of the Determination are set out in the Attachment.

Consultation

No consultation was undertaken in the making of the Determination as the instrument is machinery in nature and does not substantially alter existing arrangements.

ATTACHMENT

Notes on sections

Section 1

Section 1 provides for the name of the Determination.

Section 2

Section 2 provides that the Determination is to commence on 1 November 2006. 

Section 3

Section 3 provides that the Determination revokes Health Insurance Determination HS/01/2002.

Section 4

Section 4 defines certain terms used in the Determination.

A key term is 'relevant service' which means a service defined in paragraph 3C(8) of the Act which is specified in the Schedule of the Determination.  There are three such relevant services in the Schedule.

Subsection 4(2) provides that a reference to a provision of an Act or regulations, including the Act, the National Health Act 1953 and the regulations made under these Acts, is a reference to the provision as in force from time to time (as authorised by subsection 3C(3) of the Act).

Section 5

Section 5 specifies the circumstances in which the Determination applies.

The Determination applies in circumstances where patients had received a sacral nerve stimulation implant for the management of refractory urinary incontinence or urge retention prior to 30 April 1998 (which was originally funded under Medicare items 30000, 39134, 39139 or 39140) and require replacement or removal of the pulse generator and /or leads for the neurostimulator device.

Paragraph 5(c) of the Determination corrects a minor drafting error that appeared in paragraph 5(c) of Health Insurance Determination HS/01/2002.  In setting out one of the circumstances that needed to arise in order for Health Insurance Determination HS/01/2002 to apply to a relevant service, paragraph 5(c) of Health Insurance Determination HS/01/2002 incorrectly provided that “the relevant service” had to have been funded under Medicare prior to 30 April 1998 under items 30000, 39134, 39139 and 39140.

As evidenced by the explanatory statement to Health Insurance Determination HS/01/2002, the policy intent behind Health Insurance Determination HS/01/2002 was that it was to apply where, among other things, a patient had received a sacral nerve stimulation implant for the management of refractory urinary incontinence or urge retention prior to 30 April 1998 under Medicare item 30000, 39134, 39139 or 39140.

Accordingly, the Determination corrects the wording of the requirement in paragraph 5(c) to indicate that the sacral nerve stimulation implant service referred to in paragraph 5(a) has to have been rendered to a patient prior to 30 April 1998 and a Medicare benefit paid for that service under item 30000, 39134, 39139 or 39140.

Section 6

Paragraph 6(a) provides that a relevant service specified in the Schedule to the Determination shall 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 that make provision for medical services or professional services. 

Paragraph 6(b) provides that a relevant service is to be treated as if there were an item in the general medical services table that related to the service and specified a fee in respect of that service, being the fee specified in the Schedule to the Determination in relation to the service.

Schedule

The Schedule sets out the relevant services and assigns to each service the applicable item number, item descriptor and fee.