Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (PATHOLOGY SERVICES TABLE) AMENDMENT REGULATIONS 2003 (NO. 4) 2003 NO. 360

Subsection 133(1) of the Health Insurance Act 1973 (the Act) provides that the Governor-General may make regulations, not inconsistent with the Act, 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.

The Act provides, in part, for payment of Medicare benefits in respect of professional services rendered to eligible persons. Section 9 of the Act provides that Medicare benefits shall be calculated by reference to the fees for medical services set out in prescribed Tables.

Section 4A of the Act provides that the regulations may prescribe a table of pathology services that sets out items of pathology services, the amount of fees applicable in respect of each item and rules for interpretation of the table. The Health Insurance (Pathology Services Table) Regulations 2003 currently prescribe such a table.

The purpose of the Regulations is to amend the current table of pathology services by introducing a new item, to give effect to changes proposed in the Government's MedicarePlus package, to allow an additional amount of Medicare benefit to be paid for bulk billed services under certain circumstances.

The types of pathology services that would benefit from the proposed new item are those unreferred pathology services performed by a medical practitioner which are included in Group P9 of the Pathology Services Table, and unreferred pathology services provided by category M laboratories.

Pathology services in Group P9 are simple, basic pathology services that may be performed by a medical practitioner in the practitioner's surgery without the need to obtain Approved Pathology Authority, Approved Pathology Practitioner and Accredited Pathology Laboratory status.

Category M laboratories perform a limited range of pathology services under the direction, control and supervision of a medical practitioner, being services only for the patients of the medical practice operated by, or that employs, the medical practitioner, where the medical practice is collocated with the laboratory.

Details of the Regulations are set out in the Attachment.

The Act specifies no conditions that need to be met before the power to make the proposed Regulations may be exercised.

The Regulations commence on 1 February 2004.

ATTACHMENT

HEALTH INSURANCE (PATHOLOGY SERVICES TABLE) AMENDMENT REGULATIONS 2003 (NO. 4)

Regulation 1 provides for the Regulations to be referred to as the Health Insurance (Pathology Services Table) Amendment Regulations 2003 (No. 4).

Regulation 2 provides for the Regulations to commence on 1 February 2004.

Regulation 3 provides that Schedule 1 amends the Health Insurance (Pathology Services Table) Regulations 2003 (the Principal Regulations).

Schedule 1 - Amendments

Part 2 - Rules of interpretation

Items 1-3 insert new subrules on the application of new item 74990. This new item is described at `Part 3 - Services and Fees', below.

Item 1 inserts subrules 2(4) and 2(5). Subrule 2(4) explains the application of new item 74990 in relation to other services, and the circumstances in which a fee under new item 74990 would be payable. Subrule 2(5) defines the terms "bulk-billed", "Commonwealth concession card holder" and "unreferred service" for the purposes of new item 74990.

Item 2 inserts rule 3(2)(ab), that exempts new item 74990 from the multiple services rule (rule 3).

Item 3 amends rule 18(1)(d)(ii) to exempt an item in Groups P10, P11 and P12 (management of bulk billed services) from the coning rule [18(2-5)]. The coning rule changed the way in which pathologists were reimbursed under Medicare for pathology episodes ordered by general practitioners for non-hospitalised patients, and applies to most items listed under the Pathology Services Table of the Medicare Benefits Schedule (MBS).

Under the coning rule, where pathology tests equating to four or more MBS items of pathology testing services are ordered for a particular patient on the same day (known as a patient episode), the Medicare benefits payable will be equivalent to those for the three items with the highest Schedule fees.

Part 3 - Services and Fees

Item 4 introduces one new item numbered 74990 for the management of bulk-billed services. This item is placed in a new Group P12.

Item 74990 allows an additional amount to be payable when any unreferred service is bulk billed and provided to a person under the age of 16 or a Commonwealth concession card holder (where that person is not an admitted patient at a hospital or day-hospital facility).