Federal Register of Legislation - Australian Government

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Determinations/Health as made
This Determination enables children to seek allied health services under the Better Start for Children with Disability initiative.
Administered by: Health
Made 07 Jun 2011
Registered 20 Jun 2011
Tabled HR 21 Jun 2011
Tabled Senate 21 Jun 2011
Date of repeal 01 Jan 2014
Repealed by Health Insurance (Allied Health Services) Determination 2014

Explanatory Statement

 

Issued by the Authority of the Minister for Health and Ageing

 

Health Insurance Act 1973

 

Health Insurance (Allied Health Services) Determination 2011

 

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 general medical services table (the Table) shall, in specified circumstance and for specified statutory provisions, be treated as if it were so listed.  This Table is set out in the Health Insurance (General Medical Services Table) Regulations, remade annually.

 

Subsection 3C(8) of the Act specifies the health services about which a determination under subsection 3C(1) of the Act may be made.  These include optometrical services and any other prescribed services that relates to health.  Regulation 3A of the Health Insurance Regulations 1975 prescribes classes of allied health services as “health services” for the purposes of section 3C of the Act. 

 

The purpose of this Determination is to:

  • enable children to access audiology, occupational therapy, optometry, orthoptic, physiotherapy, psychology and speech pathology allied health services under the new Better Start for Children with Disability initiative.
  • enable children eligible for the Helping Children with Autism program to access a broader range of allied health professionals (audiologists, occupational therapists, participating optometrists, orthoptists, physiotherapists, psychologists and speech pathologists), consistent with the allied health services provided under the Better Start for Children with Disability initiative.
  • introduce orthoptists (who have previously not been eligible to provide Medicare services) and participating optometrists as eligible providers for Medicare services for the Better Start for Children with Disability initiative and the Helping Children with Autism program. 

 

This Determination revokes the Health Insurance (Allied Health Services) Determination 2010.

 

Pervasive developmental disorder and eligible disability services

The new and amended items for pervasive development disorder and eligible disability allied health services enable the payment of Medicare benefits to eligible patients of participating allied health professionals for these services.  Eligible disabilities are Down syndrome, Fragile X syndrome, cerebral palsy and specified levels of hearing loss and sight impairment. 

 


There are two new items, for:

  • assistance by an eligible audiologist, optometrist, orthoptist or physiotherapist with the diagnosis of, or development of a treatment and management plan for, a child under 13 years with pervasive developmental disorder or an eligible disability (item 82030); and
  • treatment service by an eligible audiologist, optometrist, orthoptist or physiotherapist for a child under 15 years with pervasive developmental disorder or an eligible disability (item 82035).

Amendments have been made to the following items to enable the provision of the service to a child with an eligible disability:

  • assistance by an eligible psychologist with the diagnosis of, or development of a treatment and management plan for, a child under 13 years with pervasive developmental disorder or an eligible disability (item 82000);
  • assistance by an eligible speech pathologist with diagnosis of, or development of a treatment and management plan for, a child under 13 years with pervasive developmental disorder or an eligible disability (item 82005);

·         assistance by an eligible occupational therapist with diagnosis of, or development of a treatment and management plan for, a child under 13 years with pervasive developmental disorder or an eligible disability (item 82010);

  • treatment service by an eligible psychologist for a child under 15 years with pervasive developmental disorder or an eligible disability (item 82015);
  • treatment service by an eligible speech pathologist for a child under 15 years with pervasive developmental disorder or an eligible disability (item 82020); and
  • treatment service by an eligible occupational therapist for a child under 15 years with pervasive developmental disorder or an eligible disability (item 82025).

 

References to the CEO of Medicare Australia in the Health Insurance (Allied Health Services) Determination 2010 have been changed to references to the Chief Executive Medicare throughout this Determination.  The office of CEO of Medicare Australia ceases to exist from 1 July 2011, with the abolition of Medicare Australia as an independent statutory agency.  From 1 July 2011 a new office of Chief Executive Medicare is created within the Department of Human Services. 

 


Schedule 3 of the Health Insurance (Allied Health Services) Determination 2010 has not been retained in this Determination.  That schedule provided for transitional provisions to ensure that providers of podiatry and mental health allied health services were not disadvantaged by the changes to practitioner registration following the implementation of the National Registration and Accreditation Scheme.  These transitional provisions ceased on 31 December 2010.

 

Details of this Determination are set out in the Attachment.                                                

 

Consultation

Consultation regarding the Medicare item structure and content for the new and amended pervasive developmental disorder and eligible disability services by eligible allied health professionals was provided via stakeholder consultation to advise on specific clinical issues and technical aspects during the development of the items.  Individual meetings were conducted either in person or via teleconference with representatives from each of the professional bodies listed below.  The proposed changes associated with the introduction of the new Better Start for Children with Disability initiative were well received by the stakeholders. 

 

The stakeholders consulted were medical and allied health professional bodies whose members have experience in managing and treating children with autism and disability, and included:

·      Australian Medical Association;

·      Australian Physiotherapist Association;

·      Australian Psychological Society;

·      Australian Society of Audiology;

·      Occupational Therapy Australia;

·      Optometrists Association Australia;

·      Orthoptic Association of Australia;

·      Royal Australian College of General Practitioners; and

·      Royal Australian College of Physicians (Paediatrics).

 

This Determination is a legislative instrument for the purposes of the Legislative Instruments Act 2003.

 

This Determination commences on 1 July 2011.

 

 


Attachment

 

Details of the health insurance (allied health services) determination 2011

Part 1         Preliminary

Section 1    Name of Determination

Section 1 provides that the name of the Determination is the Health Insurance (Allied Health Services) Determination 2011.

Section 2    Commencement

Section 2 provides that the Determination commences on 1 July 2011.  

Section 3    Revocation

Section 3 provides that the Health Insurance (Allied Health Services) Determination 2010 is revoked.

Section 4    Interpretation

Subsection 4(1) includes several new or amended definitions. 

 

A definition for a ‘course of assessment’ has been included, and provides that:

·                for pervasive developmental disorder services, a course of assessment is up to 4 services to which any of items 82000, 82005, 82010 or 82030 applies.  The course of assessment may only be provided following referral by a consultant physician specialising in psychiatry or paediatrics.  It must also be provided by an eligible audiologist, occupational therapist, optometrist, orthoptist, physiotherapist, psychologist or speech pathologist; and

 

·                for disability services, a course of assessment is up to 4 services to which any of items 82000, 82005, 82010 or 82030 applies.  The course of assessment may only be provided following referral by a specialist or consultant physician or a general practitioner.  It must also be provided by an eligible audiologist, occupational therapist, optometrist, orthoptist, physiotherapist, psychologist or speech pathologist.

 

The definition of ‘course of treatment’ is amended to reflect that eligible audiologists, optometrists, orthoptists and physiotherapists are now also able to provide pervasive developmental disorder services.  A definition of a ‘course of treatment’ for disability services has also been added.  The new definitions relevantly provide that:

·                a course of treatment in relation to pervasive developmental disorder services is a course of up to 10 treatment services to which any of items 82015, 82020, 82025 or 82035 applies, provided by an eligible audiologist, occupational therapist, optometrist, orthoptist, physiotherapist, psychologist or speech pathologist.  The course of treatment may only be provided following referral by a specialist or consultant physician specialising in psychiatry or paediatrics; and 

·                a course of treatment for disability services is a course of up to 10 treatment services to which any of items 82015, 82020, 82025 or 82035 applies, provided by an eligible audiologist, occupational therapist, optometrist, orthoptist, physiotherapist, psychologist or speech pathologist.  The course of treatment may only be provided following referral by a specialist, consultant physician or general practitioner.

 

The definition of ‘course of treatment’ for psychological therapy and focussed psychological therapy services is unchanged.

 

A definition of ‘disability treatment and management plan’ (DTMP) has been added.  A DTMP is a plan for the treatment and management of a child’s eligible disability to which item 137 or 139 of the Table applies. 

 

The term ‘eligible disability’ is defined as being any of:

·                Cerebral palsy;

·                Down syndrome;

·                Fragile X syndrome;

·                sight impairment resulting in vision of less than or equal to 6/18 vision or equivalent field loss in the better eye, with correction; or

·                hearing impairment resulting in either a hearing loss of 40 decibels or greater in the better ear across four frequencies, or a permanent conductive hearing loss and auditory neuropathy.

 

This definition is relevant for the new and amended pervasive developmental disorder and disability allied health services set out in Part 5 of Schedule 2.  These services may be provided to eligible children with pervasive developmental disorder or an eligible disability. 

 

Definitions for the terms ‘eligible optometrist’ and ‘eligible orthoptist’ have been added to the Determination.  These are persons who are allied health professionals in relation to the provision of optometry services and orthoptic services, respectively.  The requirements for eligibility as an optometrist and orthoptist are set out in Schedule 1 of the Determination.

 

Section 5    Treatment of allied health services

This section provides that where an allied health service is provided in accordance with the Determination it is to be treated as if it were a professional and medical service and there were an item in the Table relating to the service and specifying a fee for the service. 

 

Section 6    Limitation on certain items

This section sets out certain limitations on the provision of items 80000, 80005, 80015, 80100, 80105, 80110, 80115, 80125, 80130, 80140, 80150, 80155, 80160 and 80165.  These items only apply in a calendar year if;

·                they are one of the first 12 relevant services provided to a patient in that year; or

·                in exceptional circumstances, one of the first 18 relevant services provided to a patient in that year. 


Section 7    Referrals by psychiatrists and paediatricians for psychological therapy and focussed psychological strategies health services

This section sets out requirements for referrals to allied health providers by consultant physicians and specialists specialising in psychiatry or paediatrics for the purposes of items 80000 to 80170 in Schedule 2 of the Determination.  These requirements are unchanged from those in Health Insurance (Allied Health Services) Determination 2010

 

Section 8    Referrals by psychiatrists and paediatricians for pervasive developmental                  disorder services

Section 8 applies to items 82000 to 82035 in Schedule 2 of the Determination.

The section sets out requirements for referrals to allied health providers by consultant physicians and specialists specialising in psychiatry or paediatrics.  Minor technical amendments to subsections 8(1) – (7) have been made to reflect the inclusion of new items 82030 and 82035. 

 

New subsection 8(8) provides that if a child has previously been provided with a service mentioned in item 137 or 139 of the Table, a medical practitioner cannot refer the child for a service to which item 135 or 289 of the Table applies.

 

Section 8A          Referrals by specialists, consultant physicians and general practitioners             for disability services

New section 8A applies to items 82000 to 82035 in Schedule 2 of the Determination.

 

Subsection 8A(2) provides that for items 82000, 82005, 82010 and 82030 a referral by a specialist or consultant physician to an allied health professional must be a referral for a service to which any of items 104 to 131 or 296 to 370 (except item 359) of the Table applies.

 

Subsection 8A(3) provides that for items 82000, 82005, 82010 and 82030 a referral by a general practitioner must be a referral for a service to which any of items 3 to 51 of the Table applies.

 

Subsection 8A(4) provides that for items 82015, 82020, 82025 and 82035 a referral by a specialist or consultant physician must be a referral for a service to which item 137 of the Table applies.

 

Subsection 8A(5) provides that for items 82015, 82020, 82025 and 82035 a referral by a general practitioner must be a referral for a service to which item 139 of the Table applies.      

Subsection 8A(6) provides that if a child has previously been provided with a service mentioned in item 135 or 289 of the Table, a medical practitioner cannot refer the child for a service to which item 137 or 139 of the Table applies.

 

Section 9    Effect of election to claim private health insurance for an allied health service

Section 9 provides that an item in Schedule 2 applies to an allied health service only if a private health insurance benefit has not been claimed for the service.

 


Section 9A Pervasive developmental disorder and disability services course of assessment – reporting requirements

New section 9A applies to items 82000, 82005, 82010 and 82030 (subsection 9A(1)).  These items are provided where a practitioner has referred a child to an allied health professional for assistance with the diagnosis of the child, or so that the allied health professional may contribute to the child’s pervasive developmental or disability treatment and management plan.

 

Subsection 9A(2) provides that at the completion of a course of assessment, the allied health professional must provide a written report to the referring medical practitioner.

 

Section 10   Focussed Psychological Strategies health services

Section 10 sets out a continuing professional development (CPD) scheme for allied health professionals providing focussed psychological strategies (FPS) services. 

 

Under the scheme:

·                a person providing FPS services must complete FPS CPD each CPD year (subsection 10(1)).  To complete FPS CPD a person must complete 10 hours of CPD in subjects relevant to the provision of FPS services (see the definition of focussed psychological strategies continuing professional development in subsection 4(1)).  From 1 July 2011, a CPD year runs from 1 July to 30 June annually. 

 

·                a person providing FPS services is required to keep written records of their participation in FPS CPD (subsection 10(2)). 

 

·                where a person is registered by the Chief Executive Medicare as a provider of FPS services during the course of a CPD year (i.e. after 1 July in the relevant year), his or her CPD requirements for that year will be calculated on a pro rata basis (subsection 10(4)).

 

·                where the Minister is satisfied that a person has not completed their CPD requirements, the Minister may decide that their name should be removed from the register, and notify the Chief Executive Medicare of this decision (subsection 10(5)).  However, before notifying the Chief Executive Medicare the Minister must notify the person of the decision to remove his or her name from the register (subsection 10(6)).  The Chief Executive Medicare must not remove the person’s name from the register before receiving notification that:

o   the person has both sought a review of the decision to remove his or name from the register, and been notified that on review the decision was affirmed; or

o   the person has both sought additional time to complete the required number of CPD units, and been notified that the Minister was not satisfied that the units were completed by the expiration of the additional time; or

o   where neither of the above apply, the time in which the person may apply for a reconsideration of the decision to remove his or her name from the register has expired (subsection 10(9)).

 

·                on application to the Minister, the Minister may grant an exemption from all or part of the requirements of FPS CPD if the Minister is satisfied that special circumstances prevented a person from completing their required FPS CPD (subsection 10(8)).

 


Section 11  Reconsideration of decisions

Section 11 enables an allied health professional who has been notified of a decision by the Minister to remove his or her name from the register of allied health professionals to either:

·                apply to the Minister for a reconsideration of that decision (subsection 11(1)); or

·                request a further 28 days in which to complete the required number of units (subsections 11(6) and 11(8)).  A request for further time takes the place of a right to request a reconsideration decision under subsection 11(1) (subsection 11(7)).

 

The Minister has 28 days from the receipt of an application for reconsideration of a decision to remove a person’s name from the register to make a reconsideration decision (subsection 11(4)).  The Minister must notify the applicant in writing of the outcome of the reconsideration and reasons for the decision (subsection 11(5)).

 

Where a person who has requested further time to complete his or her FPS CPD requirements fails to complete those requirements to the Minister’s satisfaction, the Minister must proceed as if the person applied under subsection 11(1) for a reconsideration of a decision to remove the person’s name from the register of allied health practitioners (paragraph 11(9)(a)).  The Minister is required to make a reconsideration decision and notify the person in writing of the reconsideration decision and the reasons for the decision (paragraphs 11(9)(b) and (c)).

 

Under subsection 11(10) the Minister must provide a written copy of a decision made under section 11 to the Chief Executive Medicare.

 

Schedule 1 Qualification requirements for allied health professionals

Schedule 1 sets out the qualification requirements for the various types of allied health professionals. 

 

New item 11 provides that the qualification requirements for a person to be an allied health professional in relation to optometry health services are that the person is a participating optometrist.  A participating optometrist is a registered optometrist or person who employs such optometrists and who has given the Minister a common form of undertaking under s23B of the Act

 

New item 12 sets out the qualification requirements for a person to be an allied health professional in relation to orthoptic services, namely that the person is      registered with the Australian Orthoptic Board and has a Certificate of Currency and is a member of Orthoptics Australia.

 

Schedule 2 Allied health services

Schedule 2, part 5 provides the amended items 82000 – 82025 and the new items 82030 and 82035, discussed above.

 

Items 82000 – 82025 have been amended to allow children with an eligible disability to access services provided by psychologists, speech pathologists and occupational therapists.

 

Items 82030 and 82035 are new items to allow children with pervasive developmental disorder or an eligible disability to access services provided by audiologists, optometrists, orthoptists or physiotherapists.