EXPLANATORY STATEMENT
Determination by the delegate of the Minister under subsection 86E(1) of the National Health Act 1953
NATIONAL HEALTH (ENTITLEMENT TO PHARMACEUTICAL BENEFITS - SPECIAL EVIDENTIARY CATEGORIES) DETERMINATION 2001
The broad aims of Part VII of the National Health Act 1953(‘the Act’) are to assist patients to receive high quality health care through quality use of medicines, to subsidise the costs of prescribed pharmaceuticals and to provide appropriate accountability for expenditure of public funds.
To ensure accountability in respect of payments made under the Pharmaceutical Benefits Scheme (‘the PBS’) Part VII of the Act requires, amongst other things, the inclusion of medicare numbers on prescriptions for pharmaceutical benefits from 1 May 2002. These provisions are designed to ensure that benefits are supplied only to persons who are entitled to them without impeding an eligible person’s legitimate access to the PBS.
Subsection 86E(1) of the Act empowers the Minister to determine certain classes of persons whose entitlement to pharmaceutical benefits can be evidenced otherwise than by provision of medicare numbers.
Subsection 86E(2) of the Act provides that the classes that may be so determined include persons requiring drugs or medicinal preparations in an emergency and foreign persons who are covered by reciprocal health care agreements under section 7 of the Health Insurance Act 1973. Persons in the latter class may be required to produce their passport or proof of permanent residency in order to prove their entitlement to pharmaceutical benefits.
The Minister may determine classes of persons other than those listed in the specific examples in this subsection.
Subsection 86E(3) of the Act provides that a determination under subsection 86E(1) may set out the particular matters in respect of which an approved supplier must be satisfied before being satisfied that a person falls within a particular class determined under subsection 86E(1). A determination may also set out the procedure to be followed by an approved supplier in establishing such matters.
Subsection 86E(4) of the Act requires the Minister to include in each determination under subsection 86E(1) the procedure for allocating a special number applicable to a person who is a member of a particular class of persons.
Subsection 86E(5) of the Act provides that a determination under subsection 86E(1) is a disallowable instrument.
The general purpose of the National Health (Entitlement to Pharmaceutical Benefits – Special Evidentiary Categories) Determination 2001 (the Determination) is to enable persons who are entitled to pharmaceutical benefits but who, for various reasons, do not have a medicare card or whose medicare number will not be known or available at the time of supply of pharmaceutical benefits, to claim pharmaceutical benefits under the PBS (for example, some homeless people and some indigenous people). In these circumstances a designated "special number" can be used by approved suppliers in lieu of the person’s medicare number for the purpose of claiming pharmaceutical benefits. This is intended to ensure that neither the approved supplier nor the consumer is disadvantaged by enabling approved suppliers to receive payment from the Commonwealth for the supply of pharmaceutical benefits to consumers who are entitled to pharmaceutical benefits, and enabling the consumers who are entitled to pharmaceutical benefits to claim pharmaceutical benefits.
The Determination
- identifies the classes of persons to whom entitlement to pharmaceutical benefits can be authorised by provision of a special number (section 2.1);
- sets out the particular matters in respect of which an approved supplier must be satisfied before being satisfied that a person is included within a particular class (sections 2.2-2.7);
- sets out the procedure to be followed by the approved supplier in establishing such matters (section 3.2);
- lists the special numbers applicable to persons included within the specified classes of persons (section 3.1); and
- sets out procedures for allocation of special numbers (section 3.2).
The Determination identifies the following six classes of persons to whom entitlement to pharmaceutical benefits can be authorised by provision of a special number:
- Persons requiring drug or medicinal preparations in an emergency - Where a person is in an emergency and there is not enough time to establish the person’s eligibility and the pharmaceutical benefit must be supplied to the person (or the person’s agent) immediately. For example, an insulin dependent diabetic who requires an emergency supply of insulin but within a period that is too short to enable questions relating to eligibility or identity to be asked and answered.
[Sections 2.1(1)(a) and 2.2 of the determination refer]
- Foreign persons covered by reciprocal health care agreements - Australia currently has Reciprocal Health Care Agreements (RHCA) with the United Kingdom, the Netherlands, New Zealand, Malta, Italy, Sweden, Finland, and the Republic of Ireland. An approved supplier could supply pharmaceutical benefits to a person covered by a RHCA who has not been allocated a medicare number on provision of a current passport.
[Sections 2.1(1)(b) and 2.3 of the determination refer]
- Persons without medicare number who a prescriber considers are entitled to pharmaceutical benefit – Some eligible people in Australia do not have a medicare number. For example, if an indigenous person who does not have a medicare number attends a medical clinic and the doctor confirms his/her eligibility by inserting “non-medicare number service” or the applicable special number on the prescription, then the approved supplier could supply pharmaceutical benefits.
[Sections 2.1(1)(c) and 2.4 of the determination refer]
- Persons without medicare number who an approved supplier considers are entitled to pharmaceutical benefit - Where the person unable to provide a medicare number is considered by an approved supplier to be an eligible person within the meaning of the Health Insurance Act 1973 but not a person covered by a RHCA and when the approved supplier believes that
- the prescription relating to that person has resulted from a medical service not requiring a medicare number; or
- for other reasons, it is not reasonable for the person to provide a medicare number applicable to the person.
For example, a homeless young person presents a prescription from a STD clinic and is unable to provide his/her medicare details. The approved supplier forms the view that the person has received medical treatment from a health care service and s/he is an eligible person within the meaning of the Health Insurance Act 1973. The approved supplier could supply pharmaceutical benefits.
[Sections 2.1(1)(d) and 2.5 of the determination refer]
Persons requiring drugs or medicinal preparations as a matter of clinical urgency – This special number applies when the person is in a situation requiring prescription drugs and the approved supplier has reason to believe that, in his or her professional opinion, the immediate supply of the medicine is necessary to initiate urgent treatment or to continue without interruption an existing regime (urgent, but not life threatening - that is clinical urgency). For example, at the time of supply of the pharmaceutical benefit, where the supply of medicines is critical for treating chronic disease (such as anti-hypertensive agents) and the approved supplier has requested the person to provide a medicare number but a medicare number was not available. The approved supplier has no reason to believe that the person is not eligible to receive pharmaceutical benefits. The approved supplier could supply pharmaceutical benefits.
[Sections 2.1(1)(e) and 2.6 of the determination refer]
- Persons for whom an inapplicable medicare number is shown on a seemingly valid medicare card – This special number applies when the person has supplied a medicare number which subsequently turns out to be inapplicable to the person (according to Health Insurance Commission (HIC) records). The approved supplier accompanies a subsequent claim with a photocopy or photograph of the medicare card or a signed statement. The purpose of this particular provision is to enable the approved supplier to submit a further claim using same medicare number where there is no evidence before the approved supplier to suggest the medicare number is inapplicable. This is intended to protect an approved supplier who has done everything possible to verify the person's medicare number.
For example, an approved supplier makes a first claim from HIC, including an applicable medicare number. HIC finds that the supplied number does not match the records held by HIC and notifies the approved supplier. The approved supplier is unable to obtain from the person another medicare number applicable. The approved supplier would supply pharmaceutical benefits. The approved supplier makes a new claim for payment and attaches the photocopy or photograph or the signed statement for the purpose of this provision.
[Sections 2.1(1)(f) and 2.7 of the determination refer].
Part 3 of the determination sets out the particular combination of numbers that are to be the special numbers applicable to persons included within each class as a member of that class determined under Part 2, and the procedure for allocating special numbers.
This determination commences on gazettal (see section 1.2 of the determination).