EXPLANATORY STATEMENT
STATUTORY RULES 1985 NO. 5
ISSUED BY AUTHORITY OF THE MINISTER FOR HEALTH
HEALTH INSURANCE ACT 1973
HEALTH INSURANCE (VARIATION OF FEES AND MEDICAL SERVICES) (NO. 36) REGULATIONS
Section 133 of the Health Insurance Act 1973 (‘the Act’) provides, in part, that the Governor-General may make regulations 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.
Schedule 1 to the Act contains a table of medical services and rules for the interpretation of the table. The table of medical services contains items which set out the description of each medical service, and the fee for the calculation of medicare benefit applicable in each State in respect of each service.
Section 4 of the Act provides that the table of medical services in Schedule 1 to the Act may be replaced by regulations; that items or rules of interpretation in that table may be varied
or replaced by regulations; and that the regulations replacing such a table may themselves be amended by regulations. The Health Insurance (Variation of Fees and Medical Services) (No. 35) Regulations prescribe the present table of medical services pursuant to section 4 of the Act.
Section 9 of the Act provides that medicare benefits shall be calculated by reference to fees for medical services set out in the table of medical services in Schedule 1 to the Act. Medicare benefit is normally payable, in accordance with section 10 of the Act, at a rate of 85% of the relevant fee specified in the table of medical services. An additional amount of medicare benefit is payable where required to ensure that the difference between the benefit normally payable and the fee specified in the table of medical services does not exceed $10.00 in relation to a single professional service, or an aggregate of $150.00 per patient in a year in relation to multiple professional services.
Part 12 of the table of medical services contains 50 items relating to orthodontic, surgical,
general, and prosthodontic services rendered to prescribed dental patients by accredited dental practitioners for the treatment of cleft lip and cleft palate conditions. An accredited dental practitioner is a dental practitioner accredited by the Minister in writing for the purposes of the definition of that term in sub-section 3(1) of the Act. A prescribed dental patient is defined in that sub-section to mean a person who has not attained the age of 22 years and who has been certified in the approved form by a medical practitioner, or by a dental practitioner approved by the Minister for this purpose, to be suffering from cleft lip or cleft palate condition.
The Minister for Health with the concurrence of the Treasurer and the Minister for Employment and Industrial Relations agreed that the fees specified in Part 12 of the table of medical services be increased by the overall amount of 28.07% with effect from 1 February 1985. This amount had been calculated by reference, through known economic indicators, to movements since 1981 in the cost and income components of dental practice as identified
in a survey conducted by the Australian Dental Association. Except for an interim increase of 4.3% in March 1984, these fees had not been increased since the inception of the relevant items on 1 January 1981. The effect of the increases is, for example, to increase the fee specified in item 8902, relating to a professional attendance and planning of treatment by an orthodontist, from $31.50 to $40.50.
The statutory rules amend the Health Insurance (Variation of Fees and Medical Services) (No. 35) Regulations by substituting a revised Part 12, incorporating the new fees, in the table of medical services set out in the Schedule to those regulations.
The statutory rules came into operation on 1 February 1985.
Overview
The Health Insurance (Variation of Fees and Medical Services) (No. 36) Regulations 1985, issued under the authority of the Minister for Health, address the need to update the fees for medical services listed in the Health Insurance Act 1973. This legislative instrument was enacted to respond to the identified need for adjustments to the fees for dental services, particularly those associated with the treatment of cleft lip and cleft palate conditions, to reflect changes in the cost and income components of dental practice since 1981. The regulations were formulated with the concurrence of the Treasurer and the Minister for Employment and Industrial Relations, ensuring a comprehensive approach to updating the medical service fees. The objective of these amendments is to ensure that the fees specified for certain dental services are reflective of current economic conditions, thus maintaining the viability and accessibility of these essential healthcare services for patients under the Medicare scheme.
Scope and Application
The Health Insurance (Variation of Fees and Medical Services) (No. 36) Regulations, made under the Health Insurance Act 1973, apply to the fees for medical services, specifically for orthodontic, surgical, general, and prosthodontic services rendered to individuals under the age of 22 who have been certified to suffer from cleft lip or cleft palate conditions. These regulations impact accredited dental practitioners who provide these specialised services to prescribed dental patients. The Act governs the fee structure for medical services included in the table of medical services in Schedule 1, which is subject to amendment through regulations. The amendments in these particular regulations were made to adjust the fees by 28.07%, effective from 1 February 1985, reflecting economic factors such as changes in the cost and income components of dental practice. The adjustments are designed to ensure that the medicare benefits paid to accredited dental practitioners more accurately reflect the current costs of providing these services. These regulations are applicable nationally, given the overarching jurisdiction of the Commonwealth in health insurance matters. Any further modifications or clarifications to the application of these regulations may be introduced through subordinate instruments, as permitted under section 133 of the Act.
Key Provisions
The Health Insurance (Variation of Fees and Medical Services) (No. 36) Regulations amend the existing Health Insurance (Variation of Fees and Medical Services) (No. 35) Regulations, primarily by updating the fees associated with specific medical services outlined in Part 12 of the table of medical services. This part pertains to orthodontic, surgical, general, and prosthodontic services for the treatment of cleft lip and cleft palate conditions, which are rendered to patients under the age of 22 who have been certified to suffer from such conditions. Section 9 of the Act mandates that these fees are to be used in calculating the medicare benefits, with the standard benefit rate being 85% of the relevant fee, subject to adjustments to ensure the benefit does not exceed specific limits. The regulations, issued under section 133 of the Health Insurance Act 1973, reflect a 28.07% increase in fees, effective from 1 February 1985, calculated based on economic indicators since 1981.
These regulations impose specific obligations on accredited dental practitioners who provide services to prescribed dental patients. They must adhere to the updated fees outlined in the revised Part 12 of the table of medical services. Additionally, they must ensure compliance with the calculation of medicare benefits as per section 9 of the Act, maintaining accurate records to facilitate correct billing and payment processes. Accredited dental practitioners are also required to certify the eligibility of their patients in accordance with the definitions and requirements set out in the Act.
Failure to comply with the regulations, including incorrect billing or misapplication of fees, may lead to penalties. While the specific penalties are not detailed in the explanatory statement, under the Health Insurance Act 1973, breaches of regulations can result in civil or criminal penalties. Civil penalties could include fines, while criminal penalties may involve imprisonment, depending on the severity and intent of the breach. These consequences are intended to enforce adherence to the legislative framework and ensure the integrity of the medicare system.