EXPLANATORY STATEMENT
Issued
by the Authority of the Minister for Health and Ageing
Health Insurance Act 1973
Health Insurance (Gippsland and
South Eastern New South Wales
Mobile
MRI Service) Determination 2009
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 diagnostic imaging services table (the Table) shall, in specified
circumstances and for specified legislative provisions, be treated as if it were
so listed. The Table is set out in the Health Insurance (Diagnostic Imaging
Services Table) Regulations 2009 (the DIST Regulations).
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).
On 1 November 2006, the Commonwealth commenced a three year trial of a
mobile Magnetic Resonance Imaging (MRI) service operating in the Gippsland
region of Victoria and the South Eastern region of New South Wales (NSW).
Regional Imaging Pty Limited [ABN 81 095 630] (RIL) provided mobile
Medicare-eligible MRI services in these regions for the purposes of the trial.
The details of RIL’s participation in the trial were outlined in a funding
agreement between the Department of Health and Ageing and RIL. The Health
Insurance (Gippsland and South Eastern New South Wales Mobile MRI Trial)
Determination 2009 (No.3) (the Previous Determination) and earlier determinations
enabled Medicare benefits to be paid for mobile MRI services provided by RIL
pursuant to the funding agreement during the establishment period leading up to
the trial (1 July 2006 to 31 October 2006) and as part of the trial (1 November
2006 to 31 October 2009). The Previous Determination expires at the end of 31
October 2009.
The Department engaged Health Outcomes International Pty Ltd (HOI) to conduct
an independent evaluation of the trial across its three years of operation with
a final report due in February 2010.
The purpose of the Health Insurance (Gippsland and South Eastern New
South Wales Mobile MRI Service) Determination 2009 (the Determination) is to ensure that patients in Gippsland
and South Eastern NSW continue to have access to Medicare-eligible MRI services
for a 20 month transition period following the conclusion of the trial and the
expiration of the Previous Determination on 31 October 2009. The transition
period will allow time for the findings of the independent evaluation report to
be considered and appropriate ongoing arrangements for the service to be determined
by the Government.
The details of RIL’s participation in the transition period are outlined
in a funding agreement between the Department of Health and Ageing and RIL, as
in force on the day the Determination commences.
The Determination mostly reproduces the Previous Determination. The
Determination differs from the Previous Determination because of the insertion
of a new section 5A (Bulk-billing incentive) and some minor changes to the Schedule
(of specified health services and fees). These changes ensure that the Medicare
benefit and bulk billing incentive payable for services provided under the
Determination are the same as the Medicare benefit and bulk billing incentive
payable for similar services provided under the DIST Regulations (which will be
in force on 1 November 2009).
The Determination ceases to have effect at the end of 30 June 2011.
Details of the Determination are set out in the Attachment.
Consultation
The Department
of Health and Ageing has consulted with RIL about the details of the provision
of the mobile MRI service during the transition period. These details are
agreed in the funding agreement between the Department of Health and Ageing and
RIL. No other consultations with other parties were necessary.
This
Determination is a legislative instrument for the purposes of the Legislative
Instruments Act 2003.
Authority:
Section 3C of the Health Insurance Act 1973
ATTACHMENT
DETAILS OF THE HEALTH INSURANCE
(GIPPSLAND AND SOUTH EASTERN NEW SOUTH WALES MOBILE MRI SERVICE) DETERMINATION 2009
Section 1 Name of Determination
This section provides that the name of the Determination is the Health
Insurance (Gippsland and South Eastern New South Wales Mobile MRI
Service) Determination 2009.
Section 2 Commencement
This section provides that the Determination commences on 1 November 2009.
Section 3 Cessation
This section provides that the Determination will cease to have effect at 23.59,
30 June 2011.
Section 4 Interpretation
Subsection 4(1) defines terms used in the Determination.
Subsection 4(2) provides that for the avoidance of doubt, a reference to
the Act includes a reference to regulations made under the Act. Similarly, a
reference to the National Health Act 1953 includes a reference to
regulations made under that Act. Subsection 4(2) also provides that a
reference to any legislation shall be construed as a reference to that
legislation as in force from time to time. Further, a reference to the Health
Insurance (Diagnostic Imaging Services Table) Regulations 2009 is a
reference to the regulations made pursuant to section 4AA of the Act that are
in force from time to time.
Section 5 Circumstances
where this Determination applies
Subsection
5(1) and 5(2)
Subsection 5(1) provides that the Determination applies to a relevant
service where certain circumstances apply. If the relevant service is a
service described in items 63002 to 63483, the Determination will only apply to
such a service if the requirements in paragraphs 5(1)(a), 5(1)(b), 5(1)(c) and
either 5(1)(d) or 5(1)(e) are met. If the relevant service is a service
described in any of the other items listed in the Schedule, the Determination
will only apply to such a service if the requirements in paragraph 5(1)(b), 5(1)(c)
and either 5(1)(d) or 5(1)(e) are met.
The requirements set out in the various paragraphs of subsection 5(1) are
explained below.
Paragraph 5(1)(a) and subsection 5(2) provide that items 63002 to 63483
will not apply unless the service is performed pursuant to a written request
that is made by a practitioner who is a specialist, a consultant physician or
dental practitioner. The request must identify the clinical indications for
the service. These requirements correspond to the requirements for requests
for services pertaining to the equivalent items of the Table (items 63001 to
63482).
Paragraph 5(1)(b) provides that the Determination will apply where the
service is performed pursuant to the funding agreement during the transition
period. If the funding agreement is terminated, Medicare benefits will cease
to be payable under the Determination for any relevant services rendered.
Paragraph 5(1)(c) provides that the Determination will apply where the
service is performed in a permissible circumstance in accordance with one of
the subsections 5(3), 5(4), 5(5), 5(6), 5(7) or 5(8) (these subsections are
explained below).
Paragraph 5(1)(d) and 5(1)(e) set out the two alternate patients charging
requirements that must be met for the Determination to apply.
Paragraph 5(1)(d) provides that where the relevant service is a service of
a kind referred to in paragraph 10(2)(a) of the Act, the fee that RIL charges
the patient for the service must be no more than 75% of the amount specified in
the Schedule as the fee applicable to the item that relates to the service.
Subparagraph 10(2)(a)(i) of the Act refers to a service provided as part of an
episode of hospital treatment. Subparagraph 10(2)(a)(ii) refers to a service
provided as part of an episode of hospital-substitute treatment in respect of
which the person to whom the treatment is provided chooses to receive a benefit
from a private health insurer. The terms ‘hospital treatment’ and
‘hospital-substitute’ treatment have the same meaning as in the Private
Health Insurance Act 2007.
Paragraph 5(1)(e) provides that where the relevant service is not a
service to which paragraph 5(1)(d) of the Determination applies (that is, in
every case where the service is not a service of a kind referred to in
paragraph 10(2)(a) of the Act), the fee that RIL charges the patient for the
service must be no more than 85% of the amount specified in the Schedule as the
fee applicable to the item that relates to the service.
Subsection 5(3)
Relevant to paragraph 5(1)(c), subsection 5(3) provides that a relevant
service is performed in a ‘permissible circumstance’ if it is performed at Bega
and:
·
performed under the professional supervision of an eligible
provider who is available to monitor and influence the conduct and diagnostic
quality of the examination via telephone and real-time teleradiology (paragraph
5(3)(a)); and
·
reported by an eligible provider (paragraph 5(3)(b)); and
·
monitored by a medical practitioner by personal attendance on the
patient if the circumstances are such as to require on-site monitoring by a
medical practitioner (paragraph 5(3)(c)).
In relation to the provision of MRI services at Bega, due to possible
difficulties with ensuring that an eligible provider will be available on site
to supervise the performance of MRI services, paragraph 5(3)(a) provides that
supervision of such services may be conducted via teleradiology.
The term ‘teleradiology’ is defined in subsection 4(1). Under
teleradiology arrangements, a relevant service performed in Bega is to be
supervised by an eligible provider who is at another location and who is
communicating with the service site via teleradiology.
The Determination allows Medicare benefits to be payable under these
circumstances at the Bega location.
The requirement set out in paragraph 5(3)(b) that an eligible provider
provides a report on the relevant service corresponds to the reporting
requirements for services relating to items 63001 to 63482 of the Table as
specified in subrule 33(1)(b) of Schedule 1, Part 2 of the DIST Regulations.
The requirement set out in paragraph 5(3)(c) provides that if there are
circumstances that require on-site monitoring by a medical practitioner, for
example a patient who is unconscious, the items in the Schedule to the
Determination will only apply if the service is monitored by a medical
practitioner in personal attendance.
Subsection 5(4)
Subsection 5(4) provides an exception to subsection 5(3). Under
subsection 5(4), a relevant service is performed in a permissible circumstance
for the purposes of paragraph 5(1)(c) if it is performed in Bega and it is
performed in an emergency. Failure to comply with the supervision, reporting
and attendance requirements of subsection 5(3) will not prevent a Medicare
benefit being paid for a relevant service where these requirements could not be
complied with because the service was performed in an emergency.
Subsection 5(5)
Relevant to paragraph 5(1)(c), subsection 5(5) provides that a relevant
service is performed in a ‘permissible circumstance’ if it is performed during
after hours at Traralgon and:
·
performed under the professional supervision of an eligible
provider who is available to monitor and influence the conduct and diagnostic
quality of the examination via telephone and real-time teleradiology (paragraph
5(5)(a)); and
·
reported by an eligible provider (paragraph 5(5)(b)); and
·
monitored by a medical practitioner by personal attendance on the
patient if the circumstances are such as to require on-site monitoring by a
medical practitioner (paragraph 5(5)(c)); and
·
not a service to which items 63492 to 63495 are attributable
(paragraph 5(5)(d)).
This subsection replicates the permissible circumstances allowed at Bega
and described in subsection 5(3). As with Bega, there is a difficulty ensuring
that an eligible provider will be available on-site to supervise the
performances of MRI services during the after hours period at Traralgon. Consequently
paragraph 5(5)(a) provides that, in line with Bega, supervision of such
services may be conducted via teleradiology.
In addition to replicating paragraphs in subsection 5(3), subsection 5(5)
prohibits payment of Medicare benefits for services to which items 63492 to
63495 are attributable (paragraph 5(5)(d)). These services are permitted at
Bega under the teleradiology professional supervision arrangements because
patients requiring sedation, anaesthetic or a contrast MRI would otherwise have
to travel to another MRI service. However, at Traralgon these services are
available during normal hours when professional supervision is available on
site if required.
Subsection 5(6)
Subsection 5(6) provides an exception to subsection 5(5). Under
subsection 5(6), a relevant service is performed in a permissible circumstance
for the purposes of paragraph 5(1)(c) if it is performed during after hours at
Traralgon and it is performed in an emergency. Failure to comply with the
supervision, reporting and attendance requirements of subsection 5(5) will not
prevent a Medicare benefit being paid for a relevant service where these
requirements could not be complied with because the service was performed in an
emergency.
Subsection 5(7)
Relevant to paragraph 5(1)(c), subsection 5(7) provides that a relevant
service is performed in a ‘permissible circumstance’ if it is:
(a) performed under the professional supervision of an eligible
provider who is available to monitor and influence the conduct and diagnostic
quality of the examination, including, if necessary, by personal attendance on
the patient; and
(b) reported by an eligible provider.
These requirements reflect the equivalent requirements which apply to
items 63001 to 63482 of the Table as specified in subrule 33(1) of Schedule 1,
Part 2 of the DIST Regulations.
Subsection 5(8)
Subsection 5(8) provides an exception to subsection 5(7). Under
subsection 5(8), a relevant service is performed in a permissible circumstance
for the purposes of paragraph 5(1)(c) if it is performed either in an
emergency; or because of medical necessity, in a remote location. Failure to
comply with the supervision, attendance and reporting requirements of
subsection 5(7) will not prevent a Medicare benefit being paid for a relevant
service where these requirements could not be complied with because the service
was performed in an emergency; or because of medical necessity, in a remote
location.
This reflects the equivalent exception specified in subrule 33(2) of
Schedule 1, Part 2 of the DIST Regulations.
Section 5A
Bulk billing incentive
This is a new section which provides for an incentive for
eligible providers to bulk bill for services provided under the Determination
where those services are not provided in a hospital.
This new section reflects the new bulk billing incentive
available under the DIST Regulations from 1 November 2009.
Section 6 Treatment of a relevant
service
Section 6 identifies which legislative provisions will apply in respect of
a relevant service.
Paragraph 6(a) provides that all provisions of the Act, the National
Health Act 1953, regulations made under the Act and regulations made under
the National Health Act 1953 that make provision in relation to
professional services or medical services will apply to a relevant service.
(By reason of paragraphs 4(2)(a) and (b), the references to the Act and the National
Health Act 1953 in paragraph 6(a) also include references to regulations
made under these Acts).
Paragraph 6(b) provides that a relevant service shall be treated as if
there were an item in the Table that related to the relevant service and
specified the relevant fee in respect of the service.
The effect of paragraph 6(c) is that each of the items pertaining to the
relevant services is to be treated as if it is part of Group I5 of the Table
and of the relevant subgroup of Group I5 as specified in column 4 of the table
in the Schedule to the Determination. Group I5 of the Table lists all of the
MRI services included in the DIST Regulations. This means that the various
rules in the DIST Regulations which are stated to apply to items in Group I5
(eg rule 41 of Schedule 1, Part 2), or to a relevant Subgroup of Group I5 (eg
subrule 30(8) and rule 38 of Schedule 1, Part 2), will also apply to the items
for relevant services created by this Determination.
Section 7 MRI and MRA services – meaning of scan
Section 7 applies rule 37 of Schedule 1, Part 2 of the DIST Regulations to
items 63002 to 63483 of the Schedule to the Determination. Hence these items
only apply to scans which have a minimum of 3 sequences.
Section 8 MRI and MRA services – related services that can be claimed in
a 12 month period
Section 8 applies rule 39 of Schedule 1, Part 2 of the DIST Regulations to
relevant items in the Schedule to the Determination. Rule 39 caps the number
of times in any 12 month period that a Medicare benefit is payable to a person
for the particular kind of MRI service described in the specified items.
Section 9 MRI services – limit for items 63472 and 63475
Section 9 applies rule 40 of Schedule 1, Part 2 of the DIST Regulations to
items 63472 and 63475. This means that items 63470 and 63473 in the Table, and
items 63472 and 63475 in the Schedule to the Determination, will not apply to a
service so described in the item if the individual who receives the service has
previously been provided with a service described in any of the four items.
Section 10 MRI services – limit for item 63478
Section 10 provides
that item 63478 does not apply to the service described in that item if the
person to whom the service is provided has previously been provided with that
service or a service described in item 63476 of Part 3 of Schedule 1 of the DIST
Regulations.
Section 11 MRI and MRA services – modifying items
Section 11 applies rule 41 of Schedule 1, Part 2 of the DIST Regulations
to items 63492, 63493 and 63495. This means that the fee specified in these
items will apply in addition to the fee specified in another item in the
Schedule to the Determination which applies to the service (per subrule
41(1)). However, where two or more services described in item 63493 are
performed for a person on the same day, the fee specified in that item applies
to one of those services only (per subrule 41(2)). A similar rule applies in
relation to the performance of two or more services described in item 63495 for
a person on the same day (per subrule 41(3)).
Where one or
more services described in item 63493 and one or more services described in
item 63495 are performed for a person on the same day, the fee specified in
item 63493 or 63495 applies to one of those services only (per subrule 41(4)).
Section 12 Diagnostic imaging services which dental practitioners may
request
In relation to paragraph 5(2)(a), it is noted that subsection 16B(2) of
the Act limits the R-type diagnostic imaging services in respect of which a
Medicare benefit is payable where the services is requested by a dental
practitioner.
Subsection 16B(2) of the Act provides that:
“A request made by a dental practitioner, acting in his or her capacity
as a dental practitioner, for an R-type diagnostic imaging service to be
rendered is not effective for the purposes of subsection (1) unless it is a
request for a service of a kind specified in regulations made for the purposes
of this subsection.”
Regulation 10 of the Health Insurance Regulations 1975 specifies,
for subsection 16B(2) of the Act, the diagnostic imaging services that various
'types' of dental practitioners may request. Accordingly, section 12 of the
Determination operates to ensure that regulation 10 applies to services
relating to relevant items in the Schedule to the Determination.
Schedule – Specified health services
The Schedule
sets out the relevant services and assigns to each service the applicable item
number, item descriptor and fee.