A Bill for an Act to amend the law in relation to medicare benefit, and for related purposes
The Parliament of Australia enacts:
1 Short title
This Act may be cited as the Health Insurance Amendment (Safety Net) Act 2015.
2 Commencement
(1) Each provision of this Act specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.
| Commencement information |
| Column 1 | Column 2 | Column 3 |
| Provisions | Commencement | Date/Details |
| 1. Sections 1 to 3 and anything in this Act not elsewhere covered by this table | The day this Act receives the Royal Assent. | |
| 2. Schedule 1 | 1 January 2016. | 1 January 2016 |
Note: This table relates only to the provisions of this Act as originally enacted. It will not be amended to deal with any later amendments of this Act.
(2) Any information in column 3 of the table is not part of this Act. Information may be inserted in this column, or information in it may be edited, in any published version of this Act.
3 Schedules
Legislation that is specified in a Schedule to this Act is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this Act has effect according to its terms.
Schedule 1—Amendments relating to medicare safety‑net
Part 1—Amendments
Health Insurance Act 1973
1 Subsection 3(1)
Insert:
concessional person has the meaning given by section 10N.
confirmed:
(a) a person is confirmed as a member of a family at a particular time if the person is confirmed as a member of the family at that time under subsection 10FA(4); and
(b) a person is a confirmed single at a particular time if the person is a confirmed single at that time under subsection 10KA(4).
dependent child has the meaning given by subsections 10EA(5) to (9).
FTB(A) family has the meaning given by section 10MA.
FTB(A) person has the meaning given by section 10M.
member of a family: in Part II, a person is a member of a family in the circumstances set out in section 10EA, as affected by subsections 10GA(2), 10GB(2) and 10KB(2).
out‑of‑pocket expenses has the meaning given by section 10DB.
registered: a person is registered as a member of a family at a particular time if the person is registered as a member of that family under section 10E, 10EB or 10EC at that time.
relevant service has the meaning given by section 10DA, as affected by Subdivision H of Division 3 of Part II.
safety‑net amount has the meaning given by section 10R.
safety‑net expenses has the meaning given by section 10P.
safety‑net service has the meaning given by section 10BA.
safety‑net threshold has the meaning given by section 10DC.
Schedule fee, in relation to a professional service, means the fee prescribed in the table for the service.
unconfirmed single has the meaning given by section 10L.
2 Sections 8 and 8A
Repeal the sections, substitute:
Division 1—Preliminary
8AA Simplified outline of this Part
This Part deals with:
(a) the medicare benefit payable in respect of a professional service, including the circumstances in which a safety‑net amount is payable or the medicare benefit is increased or reduced because of other circumstances; and
(b) who is entitled to medicare benefit in respect of a professional service; and
(c) the process for claiming and paying medicare benefit; and
(d) other matters affecting medicare benefit.
8 Territories that are taken to form part of New South Wales
(1) For the purposes of this Part, an internal Territory is taken to form part of New South Wales.
Division 2—Entitlement to medicare benefit
8A Simplified outline for this Division
Medicare benefit is payable for medical expenses incurred in respect of a professional service rendered in Australia to an Australian resident or an eligible overseas representative.
Medicare benefit is worked out as a percentage of the Schedule fee. In some instances, that fee may be reduced or increased under a provision of this Act (such as section 15 or 16) or the regulations before the medicare benefit is worked out.
3 Section 9
Omit “(other than sections 10ACA and 10ADA)”.
4 Subsection 10(2)
Omit “A benefit in respect of a service is”, substitute “A medicare benefit in respect of a professional service is”.
5 Subsection 10(2A)
After “prescribe”, insert “professional”.
6 Subsections 10(3) and (5)
Repeal the subsections.
7 Sections 10AA to 10C
Repeal the sections, substitute:
Division 3—Medicare safety‑net
Subdivision A—Simplified outline of this Division
10A Simplified outline of this Division
Circumstances in which safety‑net amount payable
The medicare benefit payable in respect of a professional service may include a safety‑net amount in some cases. A safety‑net amount is payable for most professional services, except services provided in hospital. To receive a safety‑net amount, the sum of the out‑of‑pocket expenses for a service rendered to a person and other services rendered to the person, or a member of the person’s family, during the calendar year must equal or exceed the person’s safety‑net threshold. There are different thresholds for different people. For example, a person on a concession card has a lower threshold than a person who is not. The amount of out‑of‑pocket expenses for each service that counts towards the threshold is capped.
To receive a safety‑net amount for a service:
(a) medicare benefit must be claimed within 7 years after the end of the year in which the service is rendered; and
(b) the difference between the medical expenses for the service and the medicare benefit for the service must be paid to the person by whom or on whose behalf the service is rendered.
The safety‑net amount paid is generally 80% of the out‑of‑pocket expenses for the service, but is subject to a cap.
Families
Families are allowed to pool their out‑of‑pocket expenses, to count them towards the safety‑net threshold. To do this, the family must be registered, and the composition of the family confirmed.
A child may be registered in more than one family. In that case, medical expenses incurred by each family for the child will go towards that family’s threshold.
If, because of separation, a single family becomes 2 families during a calendar year, the medical expenses for services rendered to the children of the former family during that year before the separation will count towards the threshold for each family.
If a former spouse is confirmed as a member of a family before separation and the safety‑threshold has already been reached by a former spouse, then during the year of separation, the former spouse will continue to be treated as having reached the safety‑net threshold. The former spouse may also be registered as a member of a family, but the family will not include anyone other than the former spouse and the dependent children of the former spouse.
A child might leave a family because of separation or for other reasons. If the child is confirmed as a member of the family before the registration of the family is varied and the child has already reached the safety‑net threshold, the child will continue to be treated as having reached the safety‑net threshold. The child may be registered as a dependent child in another family.
If the child is a student, the child might choose not to be registered as a dependent child in another family, but instead register his or her own family. In that case, the student could not be treated as a member of more than one family.
A person who has previously confirmed that he or she wished to be treated as single in a calendar year may become a member of a family. However, if the person has already reached his or her safety‑net threshold, for the remainder of the year the only other people who can be registered as members of the person’s family are the person and dependent children of the person.
Subdivision B—General rule
10B Safety‑net payable
The medicare benefit payable to a person in respect of a safety‑net service is increased by the safety‑net amount for the service if Subdivisions C, D, and Q are satisfied.
10BA What is a safety‑net service?
(1) A professional service is a safety‑net service, unless it is not a safety‑net service because of this section.
(2) A professional service is not a safety‑net service if the service is rendered:
(a) as part of an episode of hospital treatment; or
(b) as part of an episode of hospital‑substitute treatment in respect of which the person to whom the treatment is rendered chooses to receive a benefit from a private health insurer.
(3) The regulations may prescribe circumstances in which more than one professional service is taken to be one safety‑net service.
(4) If the regulations are made under this section prescribing circumstances in which more than one professional service is taken to be one safety‑net service, the regulations may also prescribe, for the purposes of working out the out‑of‑pocket expenses, the safety‑net expenses or the safety‑net amount for the safety‑net service:
(a) an amount that is taken to be the Schedule fee for the safety‑net service, or the way in which that amount is to be worked out; and
(b) the expenses that are taken to be medical expenses incurred for the safety‑net service, or the way in which those expenses are to be worked out.
(5) If regulations are made under this section prescribing circumstances in which 2 or more professional services (the original services) are together taken to be one safety‑net service, none of the original services individually is a safety‑net service in those circumstances.
Subdivision C—Claim for medicare benefit made and accepted
10C Claim for medicare benefit must be made and accepted
For a safety‑net amount to be payable for a safety‑net service:
(a) a claim for medicare benefit in respect of the service must be made within 7 years after the end of the calendar year in which the service is rendered; and
(b) the claim must be accepted for payment by the Chief Executive Medicare.
Subdivision D—The safety‑net threshold
10D Safety‑net threshold must be reached
For a safety‑net amount to be payable for a safety‑net service (the current service), the sum of:
(a) the safety‑net expenses for the current service; and
(b) the safety‑net expenses for all professional services that are:
(i) relevant services for the person to whom the current service is rendered, for the calendar year in which the current service is rendered; and
(ii) claimed and accepted for payment by the Chief Executive Medicare before a claim in respect of the current service is made;
must equal or exceed the safety‑net threshold for that person for that calendar year.
10DA What is a relevant service?
(1) A professional service is a relevant service for a person for a calendar year if:
(a) the service is a safety‑net service; and
(b) the service was rendered during the calendar year; and
(c) a claim for medicare benefit in respect of the service has been made; and
(d) the Chief Executive Medicare has accepted the claim in respect of the service for payment; and
(e) an amount at least equal to the out‑of‑pocket expenses for the service has been paid directly to the person by whom or on whose behalf the service was rendered; and
(f) one of the following is satisfied:
(i) if the person is a concessional person who is not confirmed as a member of a family, an FTB(A) person who is not confirmed as a member of a family, a confirmed single or an unconfirmed single at the test time for the person for the calendar year—the service is rendered to the person;
(ii) if the person is confirmed as a member of a family at the test time for the person for the calendar year—the service is rendered to either that person or another person who is confirmed as a member of the family at that time.
(2) For the purposes of the definition of relevant service, as the term is used in section 10D, the test time for the person to whom the current service is rendered, for the calendar year in which it is rendered, is:
(a) if the claim for medicare benefit in respect of the current service is made during the calendar year—the day on which the claim is made; and
(b) if the claim for medicare benefit in respect of the current service is made after the end of the calendar year—the last day of the calendar year.
(3) For the purposes of the definition of relevant service, as the term is used in any other provision, test time has the meaning given by that provision.
10DB Working out the out‑of‑pocket expenses for a safety‑net service
Work out the out‑of‑pocket expenses for a safety‑net service by using the following formula:
10DC The safety‑net threshold
(1) The safety‑net threshold for a person to whom a safety‑net service is rendered, for a calendar year in which the service is rendered is, if the person is of a kind described in an item in column 1 of the following table when the threshold is applied, the amount set out in column 2 of that item, indexed under section 10S for that year:
| Relevant safety‑net thresholds |
| Item | Column 1 Person to whom service rendered | Column 2 Safety‑net threshold |
| 1 | a concessional person | $400 |
| 2 | an FTB(A) person | $700 |
| 3 | a person confirmed as a member of an FTB(A) family | $700 |
| 4 | a confirmed single | $700 |
| 5 | an unconfirmed single | $1,000 |
| 6 | a person confirmed as a member of a family | $1,000 |
Note 1: Families are registered under Subdivision E. The membership of a family is then confirmed under Subdivision F.
Note 2: A person is a confirmed single if the person has confirmed under Subdivision K that he or she wishes to be treated as a confirmed single. A person who is not confirmed as a single or a member of a family, and who is not an FTB(A) person or a concessional person, is an unconfirmed single under Subdivision L.
Note 3: Subdivision M deals with the rules relating to FTB(A) persons and members of an FTB(A) family.
Note 4: Subdivision N deals with the rules relating to concessional persons.
(2) If the safety‑net threshold is used for the purposes of section 10D, the safety‑net threshold is applied:
(a) for a claim for medicare benefit in respect of the current service (as defined for the purposes of that section) made during the calendar year in which the current service is rendered—on the day on which the claim is made; and
(b) for a claim for medicare benefit in respect of the current service (as defined for the purposes of that section) made after the end of the calendar year in which the current service is rendered—the last day of the calendar year.
(3) If the safety‑net threshold is used for the purposes of another provision, the safety‑net threshold is applied on the day specified in that provision.
Subdivision E—Registering a family
10E Registering a family on application
(1) A member of a family may apply to the Chief Executive Medicare at any time for registration of the family.
(2) The application:
(a) must be in the form approved by the Chief Executive Medicare; and
(b) must list the names of all persons to be registered as members of the family.
(3) The Chief Executive Medicare must register the family if:
(a) a person makes an application in accordance with this section; and
(b) the Chief Executive Medicare is satisfied that the persons listed in the application are members of the family; and
(c) the Chief Executive Medicare is not prevented from registering the family under section 10ED or 10EE.
10EA Who is a member of a family?
(1) The following are members of a person’s family:
(a) the person;
(b) the person’s spouse;
(c) each dependent child of the person or the person’s spouse.
Note: Under subsections 10GA(2), 10GB(2) and 10KB(2), there are also limits on who may be treated as a member of a family during certain periods. This will affect applications to register, or vary the registration of, a family during those periods.
Who is a spouse?
(2) A person is a spouse of another person if:
(a) the person is legally married to, and is not living on a permanent basis separately and apart from, the other person; or
(b) the person is a de facto partner of the other person.
(3) For the purposes of paragraph (2)(a), a person is not taken to be living on a permanent basis separately and apart from another person if the only reason why the persons are not living together is:
(a) a temporary absence from each other; or
(b) illness or infirmity of either or both of them.
(4) For the purposes of paragraph (2)(b), de facto partner has the meaning given by the Acts Interpretation Act 1901.
Who is a dependent child?
(5) A person is a dependent child of another person if:
(a) the person is under 16; and
(b) either:
(i) the person is in the custody, care and control of the other person; or
(ii) the person is not in the custody, care and control of any person, but is wholly or substantially in the care and control of the other person.
(6) A person is a dependent child of another person if:
(a) the person is 16 or more, but under 25; and
(b) the person is receiving full‑time education at a school, college or university; and
(c) the person is wholly or substantially dependent on the other person.
(7) For the purposes of paragraph (6)(b), a person is taken to be receiving full‑time education at a school, college or university if the only reason why the person is not receiving a full‑time education is a temporary absence from full‑time study due to illness or infirmity.
(8) A person is a dependent child of another person in any other circumstances prescribed by the regulations.
(9) A child is taken to be under a particular age for the whole of the calendar year in which the child turns that age.
10EB Varying the registration of a family on application
Adding a new family member
(1) If, at any time:
(a) a person (the new member) becomes a member of a family; and
(b) the family is registered;
the new member, or any person acting on behalf of the new member who is registered as a member of the family, may apply to the Chief Executive Medicare for a variation in the registration to add the new member.
Removing a former family member
(2) If, at any time:
(a) a person (the former member) ceases to be a member of a family; and
(b) the family is registered;
the former member, or any person acting on behalf of the former member who is registered as a member of the family, may apply to the Chief Executive Medicare for a variation in the registration to remove the former member.
Application must be in approved form
(3) An application under this section must be in the manner and form approved by the Chief Executive Medicare.
Chief Executive Medicare to vary the registration
(4) The Chief Executive Medicare must vary the registration of the family in accordance with the application if:
(a) the application is made in accordance with this section; and
(b) the Chief Executive Medicare is satisfied that:
(i) if the application is made under subsection (1)—the new member has become a member of the family; and
(ii) if the application is made under subsection (2)—the former member is no longer a member of the family; and
(c) the Chief Executive Medicare is not prevented from varying the registration of the family under section 10ED or 10EE.
10EC Registering a family, or varying a registration, other than on application—newborns
Registering a new family
(1) If:
(a) the Chief Executive Medicare reasonably believes that a newborn child is a member of a family; and
(b) the family is not registered; and
(c) the Chief Executive Medicare is not prevented from registering the family under section 10ED or 10EE;
the Chief Executive Medicare may register the family.
Varying the registration of a family
(2) If:
(a) the Chief Executive Medicare reasonably believes that a newborn child is a member of a family; and
(b) the family is registered; and
(c) the Chief Executive Medicare is not prevented from varying the registration of the family under section 10ED or 10EE;
the Chief Executive Medicare may vary the registration of the family to register the newborn child as a member of the family.
Steps to be taken before registering or varying
(3) Before registering a family under subsection (1), or varying the registration of a family under subsection (2), the Chief Executive Medicare must take such steps as are reasonable in all the circumstances to ascertain the membership of the family.
10ED No more than 2 spouses in a family
(1) The Chief Executive Medicare must not register a family if the Chief Executive Medicare reasonably believes that a person listed in the application for registration as a member of the family is a spouse (as defined in section 10EA) of more than one other person listed as a member of the family.
(2) The Chief Executive Medicare must not vary the registration of a family to include a person if the Chief Executive Medicare reasonably believes that the person is a spouse (as defined in section 10EA) of more than one other person registered, or to be registered, as a member of the family.
10EE Only dependent children may be registered in more than one family
The Chief Executive Medicare may only register a person as a member of more than one family if the person is a dependent child of a person in each of those families.
Subdivision F—Confirming the membership of a family
10F A person registered as a member of a family may confirm its composition
(1) A person who is registered as a member of a family may confirm the composition of the family.
(2) A person confirms the composition of a family by notifying the Chief Executive Medicare, in a manner and form approved by the Chief Executive Medicare, of the names of the members of the family.
10FA Chief Executive Medicare must request that family composition be confirmed
(1) This section applies if the Chief Executive Medicare reasonably believes that the medicare benefit payable in respect of a safety‑net service rendered, or that may in the near future be rendered, to a person registered as a member of a family would be increased by a safety‑net amount if the person were confirmed as a member of the family.
(2) The Chief Executive Medicare must request a person who is registered as a member of the family to confirm the composition of the family.
(3) The request must be made in the manner and form approved by the Chief Executive Medicare.
(4) Each person who is confirmed as a member of the family by notice given under section 10F is confirmed as a member of the family for the period beginning on the day specified under subsection (5) and ending on the day specified under subsection (6).
(5) The period begins:
(a) if the inclusion of a person in the composition of the family is confirmed on or after the first day of the calendar year to which the request relates but before the end of 60 days after the day on which the request is made—on the first day during the calendar year to which the request relates on which the person was registered as a member of the family; or
(b) if paragraph (a) is not satisfied—on the first day during the calendar year to which the request relates on which the inclusion of a person in the composition of the family is confirmed.
(6) The period ends on the earliest of:
(a) the day on which the registration of the family is varied under section 10EB or 10EC; or
(b) the day immediately after the calendar year ends.
Subdivision G—Consequences of changing the registration of a family after the safety‑net threshold is reached
10G Safety‑net threshold taken to have been reached for the remainder of the calendar year
(1) If:
(a) the registration of a family is varied under section 10EB during a calendar year; and
(b) immediately before the registration was varied, the sum of safety‑net expenses for the relevant services for that calendar year, for a person who was confirmed as a member of the family immediately before the variation, equalled or exceeded the safety‑net threshold;
despite the variation, for the remainder of the safety‑net year, the sum of the safety‑net expenses for the person’s relevant services for the calendar year is taken to equal or exceed the safety‑net threshold.
Meaning of test time for the definition of relevant service
(2) For the purposes of the definition of relevant service, as the term is used in this section, the test time for the person for the calendar year is immediately before the registration of the family is varied.
Meaning of remainder of the safety‑net year
(3) In this section:
remainder of the safety‑net year means the period:
(a) beginning on the day on which the registration of the family mentioned in subsection (1) is varied; and
(b) ending at the end of the calendar year in which the registration of that family is varied.
10GA Limits on registering another family—former spouse removed
Application of this section
(1) This section applies if:
(a) the registration of a family is varied to remove a person (a former spouse) as a member of the family; and
(b) the person is removed because the person is no longer the spouse of another person (a former spouse); and
(c) both former spouses were confirmed as members of the family immediately before the variation; and
(d) immediately before the variation, the sum of safety‑net expenses for the relevant services for that calendar year, for a former spouse, equalled or exceeded the safety‑net threshold.
Composition of former member’s family during the remainder of the safety‑net year
(2) Despite section 10EA, for the purposes of Subdivisions E and F the following are taken to be the only persons who are members of that former spouse’s family during the remainder of the safety‑net year:
(a) that former spouse;
(b) any dependent child of that former spouse.
Meaning of remainder of the safety‑net year and spouse
(3) In this section:
remainder of the safety‑net year means the period:
(a) beginning on the day on which the registration of the family mentioned in subsection (1) is varied; and
(b) ending at the end of the calendar year in which the registration of that family is varied.
spouse has the meaning given by section 10EA.
10GB Limits on registering another family—dependent child removed
Application of this section
(1) This section applies if:
(a) the registration of a family is varied to remove a person (the former member) as a member of the family; and
(b) the former member was registered as a member of the family because the former member was a dependent child of another member of the family; and
(c) the former member was confirmed as a member of the family immediately before the variation; and
(d) immediately before the variation, the sum of safety‑net expenses for the relevant services for that calendar year for the former member equalled or exceeded the safety‑net threshold.
Former member’s family for remainder of safety‑net year
(2) Despite section 10EA, for the purposes of Subdivisions E and F the former member is only to be treated as a member of a family with other persons during the remainder of the safety‑net year in either of the following circumstances:
(a) if the former member is a dependent child of another person (as defined in section 10EA), the former member may be treated as a member of the other person’s family;
(b) each dependent child of the former member may be treated as a member of the former member’s family.
Note: Under section 10EE, the former member could not be registered both as a dependent child of one family, and in a separate family with the former member’s own dependent children.
Meaning of remainder of the safety‑net year
(3) In this section:
remainder of the safety‑net year means the period:
(a) beginning on the day on which the registration of the family mentioned in subsection (1) is varied; and
(b) ending at the end of the calendar year in which the registration of that family is varied.
Subdivision H—Where children are registered in more than one family
10H Application of this Subdivision
This Subdivision applies if:
(a) a person (the child) is registered as a member of more than one family at a particular time during a calendar year, because the person is a dependent child of a person in each of those families; or
(b) a person (the child) who was a dependent child of a person in one family during a calendar year then, during that year, ceases to be registered as a member of that family and is registered as a member of another family because the person is a dependent child of a member of that other family.
10HA Working out whether the safety‑net threshold has been reached for the child
If a safety‑net service is rendered to the child during the calendar year (the current service), the safety‑net threshold for the child for the calendar year is reached or exceeded by the current service only if:
(a) ignoring all relevant services for the child for the year other than those rendered to the child, the safety‑net threshold for the child for the year would have been reached or exceeded; or
(b) taking into account only those relevant services for the child for the year for which medical expenses were incurred by the family responsible for the current service, the safety‑net threshold for the child for the year would have been reached or exceeded.
Example: Mary, her father Trent and Trent’s partner are registered as members of Family A. Mary and her mother Jane are registered as members of Family B. No member of either family is a concessional person and the families are not FTB(A) families.
Mary goes to the doctor in October 2016. A safety‑net service is rendered to Mary (the current service). She has already been to the doctor on a number of occasions in April and May of 2016. The services rendered to Mary on those occasions were also safety‑net services.
Jane incurs medical expenses for the current service, of which $100 are out‑of‑pocket expenses. She also incurred the medical expenses for some of the services rendered to Mary in April and May. The out‑of‑pocket expenses incurred for those services totalled $500. Trent incurred medical expenses for the remainder of the services rendered to Mary in that period. The out‑of‑pocket expenses for those services totalled $450.
Jane has incurred $200 in out‑of‑pocket expenses for safety‑net services rendered to her during the year, and claimed before the claim for the current service was made.
Jane claims medicare benefit for the current service in November 2016 and confirms the composition of Family B at the time the claim is made.
The total out‑of‑pocket expenses incurred for safety‑net services rendered to Mary during the year is $1,050. She has been confirmed as a member of Family B. So, relying on paragraph 10HA(a), the safety‑net threshold of $1,000 for Mary has been exceeded.
Mary would not have reached the safety‑net threshold under paragraph 10HA(b). The sum of the out‑of‑pocket expenses for Jane ($200), and the out‑of‑pocket expenses for Mary for safety‑net‑services for which Jane incurred medical expenses ($600), is less than the safety‑net threshold of $1,000 for Mary as a confirmed member of Family B. However, this does not matter, as the safety‑net threshold has already been reached under paragraph 10HA(a).
10HB Working out whether the safety‑net threshold has been reached for another member of one of the child’s families
If a safety‑net service is rendered to a member of one of the families (other than the child) during the calendar year (the current service), for the purposes of working out whether the safety‑net threshold for that member for the calendar year is reached or exceeded by the current service, ignore those relevant services rendered to the child during the year for which medical expenses were not incurred by the family responsible for the current service.
Example: Mary, her father Trent and Trent’s partner are registered as members of Family A. Mary and her mother Jane are registered as members of Family B. No member of either family is a concessional person and the families are not FTB(A) families.
Trent goes to the doctor in December 2016. It is his only visit to the doctor for the year. A safety‑net service (the current service) is rendered and Trent makes a claim for the service on the same day. He confirms the membership of Family A at the time the claim is made. The out‑of‑pocket expenses incurred by Trent for the current service are $150.
Mary has been to the doctor on a number of occasions in April, May and October 2016. The services rendered to Mary are safety‑net services. On some occasions, Jane incurred the medical expenses for the service. The out‑of‑pocket expenses on those services total $600. On others, Trent incurred the medical expenses for the service. The out‑of‑pocket expenses on those services total $550. Medicare benefit has been claimed for all of the services rendered to Mary.
Trent’s partner has also incurred medical expenses for safety‑net services rendered to her during the year, and claimed medicare benefit for those services. The out‑of‑pocket expenses for those services total $400.
Trent has exceeded the safety‑net threshold of $1,000, as a confirmed member of family A.
In working out whether Trent has reached or exceeded the safety‑net threshold with the out‑of‑pocket expenses for the current service, those services rendered to Mary for which Trent has incurred medical expenses are taken into account ($550). Those services rendered to Mary for which Jane has incurred medical expenses are ignored.
The out‑of‑pocket expenses for the services rendered to Trent ($150) and Trent’s partner ($400), are then added to those for Mary that are taken into account ($550). The total is $1,100.
10HC Safety‑net services rendered to the child during the year of separation
If:
(a) a safety‑net service (the earlier service) is rendered to the child during the calendar year in which the current service is rendered; and
(b) medicare benefit in respect of the earlier service was claimed and accepted for payment by the Chief Executive Medicare before a claim in respect of the current service was made; and
(c) the child was registered as a member of a family (the former family at the time the claim for medicare benefit in respect of the earlier service was made; and
(d) another person, who was registered as a member of the former family at the time the claim for medicare benefit in respect of the earlier service was made, incurred medical expenses for the earlier service; and
(e) during the calendar year in which the current service is rendered, the former family has ceased to be registered, or the registration of the former family has been varied, because persons who were registered as members of the former family at the time the earlier service was rendered are no longer spouses; and
(f) either:
(i) the former family is responsible for the current service; or
(ii) a person who was registered as a member of the former family at the time the claim for medicare benefit in respect of the earlier service was made, because the person was a spouse of another member of the former family, is a member of the family responsible for the current service;
then, for the purposes of this Subdivision, the earlier service is taken to be a relevant service for each member of the family responsible for the current service for the calendar year in which the current service is rendered.
Example: Jennifer, Alex and their son Max are registered as a family in January 2016 (the former family).
Max goes to the doctor in February 2016 and a safety‑net service is rendered. Jennifer incurs medical expenses for the service, makes a claim for medicare benefit on the same day the service is rendered.
Alex and Jennifer separate in June 2016. The registration of the former family is varied to remove Alex. Jennifer and Max remain registered as members of the former family. Alex registers himself and Max as members of a new family.
Max goes to the doctor in August 2016 and a safety‑net service is rendered. Alex incurs medical expenses for the service, makes a claim for medicare benefit and confirms the composition of the new family on the same day the service is rendered. Alex then goes to the doctor in September 2016 and a safety‑net service is rendered. Alex incurs medical expenses for the service (the current service) and makes a claim for medicare benefit.
In working out whether Alex has reached or exceeded the safety‑net threshold with the out‑of‑pocket expenses for the current service, the out‑of‑pocket expenses for the service rendered to Max in February 2016 and in August 2016 are both taken into account, along with the out‑of‑pocket expenses for the current service.
10HD Definitions
Meaning of family responsible for the current service
(1) For the purposes of this Subdivision, a family incurs medical expenses as the family responsible for the current service if the person who incurs medical expenses for the current service is confirmed as a member of the family at the test time.
Meaning of test time
(2) For the purposes of this Subdivision, including the definition of relevant service as the term is used in this Subdivision, the test time for a person to whom the current service is rendered or who incurs medical expenses for the current service, for the calendar year in which it is rendered, is:
(a) if the claim for medicare benefit in respect of the current service is made during that calendar year—the day on which the claim is made; and
(b) if the claim for medicare benefit in respect of the current service is made after the end of that calendar year—the last day of the calendar year.
Subdivision J—Other consequences of varying the registration of a family
10J Registration varied—addition of a new member
If:
(a) a person becomes a member of a family after it is registered; and
(b) the family’s registration is varied to reflect that change; and
(c) medicare benefit has already been paid in respect of a safety‑net service rendered to the new family member, or any other member of the family;
no increase in that benefit is payable because of the new composition of the family.
Subdivision K—Confirmed singles
10K Notice confirming that a person wishes to be treated as a confirmed single
(1) A person may give the Chief Executive Medicare notice that the person wishes to be treated as a confirmed single.
(2) The notice must be given in the manner and form approved by the Chief Executive Medicare.
10KA Chief Executive Medicare must request that person confirm that wishes to be treated as a confirmed single
(1) This section applies if the Chief Executive Medicare reasonably believes that the medicare benefit payable in respect of a safety‑net service rendered, or that may in the near future be rendered, to a person would be increased by a safety‑net amount if the person were a confirmed single.
(2) The Chief Executive Medicare must request the person to give the Chief Executive Medicare notice under section 10K if the person wishes to be treated as a confirmed single.
(3) The request must be made in the manner and form approved by the Chief Executive Medicare.
(4) If the person gives the Chief Executive Medicare notice under section 10K that the person wishes to be treated as a confirmed single, the person is a confirmed single for the period beginning at the time specified under subsection (5) and ending at the time specified under subsection (6).
(5) The period begins:
(a) if the person has given notice under section 10K on or after the first day of the calendar year to which the request relates but before the end of 60 days after the day on which the request is made—on the first day during the calendar year to which the request relates on which the person was not a concessional person, an FTB(A) person or registered as a member of a family; or
(b) if paragraph (a) is not satisfied—on the first day during the calendar year to which the request relates on which the person gives notice under section 10K that the person wishes to be treated as a confirmed single.
(6) The period ends on the earliest of:
(a) the day on which the person is registered as a member of a family under section 10E or 10EB; or
(b) the day immediately after the calendar year ends.
10KB Confirmed single becomes a member of a family
Application of this section
(1) This section applies if:
(a) an application is made under section 10E or 10EB to register a person who is a confirmed single as a member of a family; and
(b) during the calendar year in which the decision on the application is made, but before the decision is made, the sum of safety‑net expenses for the relevant services for that calendar year for the person equalled or exceeded the safety‑net threshold.
Composition of family for remainder of the safety‑net year
(2) Despite section 10EA, during the remainder of the safety‑net year, the following are taken to be the only persons who are members of the person’s family:
(a) the person;
(b) any dependent child of the person.
(3) In this section:
remainder of the safety‑net year is the period:
(a) beginning on the day on which the decision on the application is made; and
(b) ending at the end of the calendar year the decision on the application is made.
Subdivision L—Unconfirmed singles
10L Meaning of unconfirmed single
A person is an unconfirmed single at a particular time if the person is not one of the following at that time:
(a) a concessional person;
(b) an FTB(A) person;
(c) a person confirmed as a member of a family;
(d) a confirmed single.
Subdivision M—FTB(A) persons and members of FTB(A) families
10M Meaning of FTB(A) person
(1) A person is an FTB(A) person at all times during a calendar year (the safety‑net year):
(a) after the first time in the safety‑net year that the person receives a payment of an instalment of family tax benefit under section 23 of the A New Tax System (Family Assistance) (Administration) Act 1999 that has a Part A rate that is greater than nil; or
(b) after the person receives a payment of family tax benefit under section 24 of the A New Tax System (Family Assistance) (Administration) Act 1999 that has a Part A rate that is greater than nil and that is in respect of the last income year (within the meaning of that Act) ending before the start of the safety‑net year; or
(c) if a determination for the purposes of this paragraph is in force under subsection (2)—after the time specified in, or worked out in accordance with, the determination.
Note: The Part A rate is calculated under Schedule 1 to the A New Tax System (Family Assistance) Act 1999.
(2) The Minister may, by legislative instrument, determine that a person is an FTB(A) person for the purposes of paragraph (1)(c).
(3) The determination must specify the time, or how to work out the time, after which the person is an FTB(A) person for the purposes of the paragraph.
10MA Meaning of FTB(A) family
A group of persons registered as a family is an FTB(A) family at a particular time during a calendar year if, at that time, an FTB(A) person is confirmed as a member of the family.
Subdivision N—Concessional persons
10N Meaning of concessional person
A person is a concessional person at all times during a calendar year after the first time in that year that the person is a concessional beneficiary for the purposes of Part VII of the National Health Act 1953 (which deals with pharmaceutical benefits).
Subdivision P—Safety‑net expenses
10P Working out safety‑net expenses
(1) The amount of the safety‑net expenses for a safety‑net service is:
(a) the out‑of‑pocket expenses for the service; or
(b) if the out‑of‑pocket expenses for the service exceed the maximum amount to be included in safety‑net expenses for the service—the maximum amount to be included in safety‑net expenses for the service.
(2) The maximum amount to be included in safety‑net expenses for a safety‑net service is worked out using the formula:
(3) In this section:
basic medicare benefit for the service means the medicare benefit that would be payable in respect of the service, ignoring any increase in the medicare benefit by a safety‑net amount.
fee for the service means:
(a) the Schedule fee for the service; or
(b) if:
(i) the service is taken to be a safety‑net service because of regulations made for the purposes of subsection 10BA(3) (more than one professional service taken to be a single safety‑net service); and
(ii) under regulations made for the purposes of this subparagraph, an amount that is higher than the Schedule fee for the service, or a way of working out such a higher amount, is prescribed;
the higher amount.
threshold percentage for a safety‑net service is 150%.
(4) If an amount worked out under subsection (2) is not a multiple of 1 cent, that amount is to be rounded up to the nearest cent.
Assumptions when working out safety‑net expenses for the purposes of paragraph 10D(a) and subsection 10R(3)
(5) In working out the amount of the safety‑net expenses for the purposes of paragraph 10D(a) and subsection 10R(3) (safety‑net expenses for the current service), assume that no safety‑net amount is payable in respect of the current service.
Subdivision Q—Amount paid to the practitioner
10Q Amount paid to practitioner
For a safety‑net amount to be payable for a safety‑net service, an amount must be paid directly to the person by whom or on whose behalf the service was rendered that is at least the difference between:
(a) the medical expenses incurred for the service; and
(b) the medicare benefit that would be payable in respect of the service.
Note: If a safety‑net amount is payable for the service the medicare benefit payable for the service would include the safety‑net amount.
Subdivision R—Safety‑net amount
10R Working out the safety‑net amount
(1) The safety‑net amount for a safety‑net service (the current service) is:
(a) the adjusted expenses for the current service (see subsections (2) and (3)); or
(b) if the adjusted expenses for the current service exceed the maximum safety‑net amount for the service (see subsection (4))—the maximum safety‑net amount for the service.
Adjusted expenses
(2) If the sum of the safety‑net expenses for all relevant services for the person to whom the current service was rendered, for the calendar year in which it was rendered, is equal to or greater than the safety‑net threshold for that person, work out the adjusted expenses for the current service by using the following formula and, if the result is not a multiple of 5 cents, rounding the result up to the nearest multiple of 5 cents:
(3) If the sum of the safety‑net expenses for all relevant services for the person to whom the current service was rendered, for the calendar year in which it was rendered, is less than the safety‑net threshold for that person, but the threshold would be reached if the safety‑net expenses for the current service were added, work out the adjusted expenses for the current service using the following formula and, if the result is not a multiple of 5 cents, rounding the result up to the nearest multiple of 5 cents:
where:
balance of safety‑net threshold means the amount by which the sum of the safety‑net expenses for the relevant services for the person for the calendar year is less than the safety‑net threshold for the person.
Maximum safety‑net amount
(4) Work out the maximum safety‑net amount for the current service using the following formula and, if the result is not a multiple of 5 cents, rounding the result up to the nearest multiple of 5 cents:
(5) For the purposes of the definition of relevant service, as the term is used in this section, the test time for the person to whom the current service is rendered, for the calendar year in which it is rendered, is:
(a) if the claim for medicare benefit in respect of the current service is made during that calendar year—the day on which the claim is made; and
(b) if the claim for medicare benefit in respect of the current service is made after the end of that calendar year—the last day of the calendar year.
(6) In this section:
basic medicare benefit for the current service means the medicare benefit that would be payable in respect of the current service, ignoring any increase in the medicare benefit by a safety‑net amount.
fee for the current service means:
(a) the Schedule fee for the current service; or
(b) if:
(i) the current service is taken to be a safety‑net service because of regulations made for the purposes of subsection 10BA(3) (more than one professional service taken to be a single safety‑net service); and
(ii) under regulations made for the purposes of this subparagraph, an amount that is higher than the Schedule fee for the current service, or a way of working out such a higher amount, is prescribed;
the higher amount.
safety‑net cap percentage for a safety‑net service is 150%.
Subdivision S—Other matters
10S Indexing the safety‑net threshold
(1) In this section:
index number, in relation to a quarter, means the All Groups Consumer Price Index number that is the weighted average of the 8 capital cities and is published by the Australian Statistician in respect of that quarter.
year, for the purpose of the indexation of the safety‑net threshold for safety‑net services, means the year beginning on 1 January 2016 or a later year beginning on 1 January.
(2) The amount of the safety‑net threshold for a safety‑net service is to be indexed under this section on 1 January of every year (the indexation day) by using the September reference quarter.
(3) Where an amount is to be indexed on the indexation day, this Act has effect as if the indexed amount were substituted for that amount on that day.
(4) The indexed amount for an amount to be indexed is:
(a) the amount worked out by multiplying the amount to be indexed by the indexation factor for that amount; or
(b) if the amount worked out under paragraph (a) is not a multiple of 10 cents—that amount rounded down to the nearest multiple of 10 cents.
(5) Subject to subsections (6), (7) and (8), the indexation factor for an amount to be indexed on an indexation day is the amount worked out by using the formula:
where:
most recent index number means the index number for the last quarter before the indexation day that is a reference quarter for the indexation of the amount.
previous index number, in relation to the indexation of an amount referred to in subsection (2), means the index number for the reference quarter in that item immediately before the most recent reference quarter in that item ending before the indexation day.
(6) An indexation factor is to be worked out to 3 decimal places.
(7) If an indexation factor worked out under subsections (5) and (6) would, if it were worked out to 4 decimal places, end in a number that is greater than 4, the indexation factor is to be increased by 0.001.
(8) If an indexation factor worked out under subsections (5), (6) and (7) would be less than 1, the indexation factor is to be increased to 1.
(9) Subject to subsection (10), if at any time (whether before or after the commencement of this section), the Australian Statistician publishes an index number for a quarter in substitution for an index number previously published by the Statistician for that quarter, the publication of the later index number is to be disregarded for the purposes of this section.
(10) If at any time (whether before or after the commencement of this section) the Australian Statistician changes the index reference period for the Consumer Price Index, regard is to be had, for the purposes of applying this section after the change takes place, only to index numbers published in terms of the new index reference period.
Division 4—Medicare benefits not to exceed medical expenses incurred
11 Simplified outline of this Division
Medicare benefit is generally not payable for a professional service to the extent that the benefit would exceed the medical expenses incurred for the service.
8 After section 14
Insert:
Division 5—Circumstances in which medicare benefits not payable or require different calculation
14A Simplified outline of this Division
Medicare benefit is not payable, or is reduced, in respect of expenses incurred for some professional services or in certain circumstances. This may occur if:
(a) 2 or more operations are performed on a person on the same occasion; or
(b) the medicare benefit is in respect of the administration of an anaesthetic during an operation and the practitioner administering the anaesthetic is not also performing, or assisting with, the operation; or
(c) more than one practitioner performs a service for an operation (that is, assists at the operation, administers the anaesthetic or assists the anaesthetist in administering the anaesthetic).
Medicare benefit will generally only be payable in respect of pathology services, diagnostic imaging services and radiation oncology services if the service is determined to be necessary by certain practitioners and the rendering of, or in some cases the request for, the service meets the requirements for the service set out in this Division.
The Division sets out a number of other circumstances in which Medicare benefit is not payable.
9 Paragraph 19CA(4)(b)
Before “benefit”, insert “a medicare”.
10 After section 19DB
Insert:
Division 6—Who is entitled to medicare benefit and claims process
19DC Simplified outline of this Division
Medicare benefit may be paid directly to the person who incurs medical expenses for the professional service to which the expense relates (see section 20).
However, under section 20A, if the practitioner by whom or on whose behalf the service is rendered accepts assignment of medicare benefit in full payment of those medical expenses, the medicare benefit may be paid directly to the practitioner.
11 Before subsection 20(1)
Insert:
Medicare benefit payable to person who incurs medical expenses
12 Before subsection 20(1A)
Insert:
Manner in which medicare benefit paid
13 Subsection 20(1A)
Omit “and (2A)”, substitute “and (2A) to (2C)”.
14 Before subsection 20(1B)
Insert:
Paying medicare benefit electronically
15 Before subsection 20(2)
Insert:
Issuing a cheque to the medicare benefit recipient payable to the practitioner
16 Subsection 20(2A)
Repeal the subsection, substitute:
Issuing a cheque where a safety‑net amount is payable as part of the medicare benefit
(2A) Subsections (2B) and (2C) apply if:
(a) the medicare benefit payable to a person in respect of a safety‑net service is increased by the safety‑net amount for the service; and
(b) the person has not paid the whole of the medical expenses that the person incurred in respect of the service.
(2B) If the medicare benefit is less than, or equal to the unpaid amount:
(a) the person is not to be paid the medicare benefit; and
(b) if the person requests it, there will, instead of that payment, be given to the person personally, or sent to the person by post at the person’s last known address, a cheque for the amount of the medicare benefit drawn in favour of the person by whom, or on whose behalf, the safety‑net service was rendered.
(2C) If the medicare benefit is more than the unpaid amount:
(a) the person is not to be paid so much of the medicare benefit as is equal to the unpaid amount; and
(b) if the person requests it, there will, instead of that payment, be given to the person personally, or sent to the person by post at the person’s last known address, a cheque for that amount of the medicare benefit drawn in favour of the person by whom, or on whose behalf, the safety‑net service was rendered.
17 Before subsection 20(3)
Insert:
Direct payment to practitioner where cheque not presented
18 Paragraph 20(3)(a)
Omit “or (2A)”, substitute “, (2B) or (2C)”.
19 Subsection 20(3)
Omit “an amount equal to the amount of the medicare benefit”, substitute “an amount equal to the amount of the cheque”.
20 Subsection 20(4)
Omit “or (2A)” (wherever occurring), substitute “, (2B) or (2C)”.
21 After section 20B
Insert:
Division 7—Other matters affecting medicare benefit
20BAA Simplified outline of this Division
This Division deals with a variety of other matters, including undertakings by persons such as participating midwives, participating nurse practitioners and participating optometrists who may provide professional services that attract medicare benefit.
22 Subsection 21A(3)
Before “service” (wherever occurring), insert “professional”.
23 Subsection 22(3)
Before “service” (wherever occurring), insert “professional”.
24 Paragraph 23A(2)(a)
Before “service”, insert “professional”.
25 Paragraph 23A(2)(e)
Omit “the benefits payable”, substitute “the medicare benefits payable”.
Part 2—Application of amendments
26 Application of Part 1
The amendments made by Part 1 of this Schedule apply in relation to professional services rendered on or after 1 January 2016.