Federal Register of Legislation - Australian Government

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Dental Benefits Rules 2013

Authoritative Version
Rules/Other as made
These rules establish the operational framework and service items for the Child Dental Benefits Schedule - Grow Up Smiling.
Administered by: Health
Registered 26 May 2013
Tabling HistoryDate
Tabled HR27-May-2013
Tabled Senate17-Jun-2013
Date of repeal 01 Jan 2015
Repealed by Dental Benefits Rules 2014

 

Explanatory Statement

 

Issued by the Authority of the Minister for Health

 

Dental Benefits Act 2008

 

Dental Benefits Rules 2013

 

Subsection 60(1) of the Dental Benefits Act 2008 (the Act) provides that the Minister may, by legislative instrument, make Dental Benefits Rules providing for matters required or permitted by the Act to be provided, or necessary or convenient to be provided in order to carry out or give effect to the Act.

 

The Dental Benefits Rules 2013 (the Rules) establish the operational framework and service items for the Child Dental Benefits Schedule – Grow Up Smiling, as announced by the Government on 29 August 2012. Grow Up Smiling forms part of the Government’s dental health reform initiatives and aims to expand access to dental services for children.

 

The Rules will repeal the Dental Benefits Rules 2009 (the Former Rules) and discontinue its associated Medicare Teen Dental Plan.  Under the Medicare Teen Dental Plan, patient eligibility was limited to teenagers aged between 12-17 years.  The Medicare Teen Dental Plan provided an annual benefit of up to $166.15 for a basic prevention service only.  Grow Up Smiling will expand the age range of eligibility to children aged at least 2 years but under 18 years.  It will also provide eligible children with increased benefits of up to $1,000 capped over two calendar years for both basic prevention and treatment services.

 

The Rules introduce additional provider requirements into the dental benefits operational framework.  The first provider requirement is for providers to obtain consent to treatment and informed financial consent prior to commencing any Grow Up Smiling services.  This consent must be recorded in writing on a patient consent form and signed by the patient or patient’s guardian.  The patient consent form rule aims to increase the flow of communication between the provider and patient and assist financially disadvantaged families to plan for any out-of-pocket costs they may be charged.  Obtaining consent is a requirement for the payment of benefits, and does not affect any other legal requirements to obtain consent that might exist.  The second requirement is for providers to keep clinical records of Grow Up Smiling services for a period of four years.  This requirement aims to ensure records are available for appropriate auditing of provider compliance with requirements for providing services.  Again, this requirement does not affect any other legal requirement that might exist to maintain clinical records.

 

The Rules also introduce a framework into Grow Up Smiling that will provide an incentive for State and Territory Governments to maintain their existing activity levels and expenditure on dental services as well as meet certain other conditions.  The Rules provide a date after which benefits cannot be paid for a service provided by the public dental system in each state.  The Minister for Health may review and extend this date in future for states and territories that meet the policy requirements set out by the Minister.  A one-year grace period is provided.

 

The process by which these requirements are set and compliance against them is demonstrated by states and territories does not (and is not intended to) form part of the legislation.  This process will be managed by the Department of Health and Ageing on instruction from the Minister for Health.  The Minister’s decisions will be reflected in future legislative instruments.

 

As with the administrative arrangements of the Medicare Teen Dental Plan, the Department of Human Services will be responsible for administering the payment of dental benefits and the compliance management framework for Grow Up Smiling.

 

These Rules commence on 1 January 2014.

 

Consultation

The Department of Health and Ageing (the Department) undertook a formal public consultation process in May 2013 to seek feedback and written submissions from stakeholders on the design of Grow Up Smiling. 

 

The consultation process was managed online through the Department’s consultation hub.  Key interest groups were formally invited to participate in the consultation process, including peak dental professional organisations, private provider representatives, state and territory public providers, consumer representatives, registration and regulation bodies, academics and Aboriginal and Torres Strait Islander organisations.  The consultation hub was also open to other organisations and members of the public to give all interested stakeholders the opportunity to voice concerns, provide feedback and input to the design of Grow Up Smiling.  Suggestions and feedback provided through the consultation process were considered in the drafting of the Rules.

 

The Department consulted the Department of Human Services on the implementation of the programThe Department also consulted the Commonwealth departments and agencies responsible for the income support programs used to determine patient eligibility (the Department of Families, Housing, Community Services and Indigenous Affairs and the Department of Veterans’ Affairs).

 

The Office of Best Practice Regulation has advised that a Regulation Impact Statement is not required for these Rules.

 

Authority: Section 60(1) of the  
                  Dental Benefits Act 2008


Attachment

 

Details of the DENTAL BENEFITS RULES 2013

 

1.       Name of Rules

Rule 1 provides for the Rules to be referred to as the Dental Benefits Rules 2013.

 

2        Commencement

Rule 2 provides for the Rules to commence on 1 January 2014.

 

3        Revocation

Rule 3 revokes the Dental Benefits Rules 2009.

 

4        Definitions

Rule 4 defines specific terms used in the Rules.

 

5        Dental Benefits Schedule

Rule 5 provides for the Dental Benefits Schedule, which sets out the item numbers, service descriptors and dental benefits payable. 

 

6        Dental providers (Act, s. 6)

Rule 6 specifies that dentists (dental practitioners who have general registration in the Division of Dentists under a law of a State or Territory) and dental specialists (dental practitioners who have specialist registration in the Division of Dentists under a law of a State or Territory) who have a Medicare provider number are “dental providers” for the purposes of the Act, and therefore eligible to provide the services listed in Schedule 1 of the Dental Benefits Schedule. 

 

7        Persons eligible to render services on behalf of dental providers

(Act, paragraph 7(a))

Rule 7 specifies that dental hygienists, dental therapists, dental prosthetists and oral health therapists are eligible to provide services listed in Schedule 1 on behalf of a dental provider.

 

A dental service in Schedule 1 may also be rendered on behalf of a public sector dental provider by another public dental sector provider.  This allows for the operation of administration arrangements for billing in the public sector.

 

8        Particulars to be recorded (Act, ss. 17(2))

Rule 8 specifies the details that must be recorded on the account, receipt, or assignment of benefit form (as the case requires) in order for a dental benefit for a service item listed in Schedule 1 to be payable.  There are slightly different requirements depending on whether the service is patient billed (where the dentist will issue an account or receipt to the patient) or bulk billed (where a form approved by the Chief Executive Medicare will be used).

 

8A     Dental benefits not payable unless conditions satisfied

(Act, paragraph 18(2)(e))

Rule 8A specifies that services provided by or under an arrangement with a state or internal territory are eligible for dental benefits only if the service was provided on or before the date in respect of that state in Schedule 2.  It provides the mechanism by which the Minister’s requirement that states not withdraw funding for dental services in response to Commonwealth funding will be given effect.

 

Schedule 2 of the Dental Benefits Schedule lists the date after which each state or territory government may no longer access Grow Up Smiling, and access to Grow Up Smiling in that state will be limited to private providers only.

 

Rule 8A allows the Minister to make exceptions to the above, allowing certain access for public providers even if the date in Schedule 2 has been passed.

 

9        Classes of persons who satisfy the means test (Act, paragraph 24(1)(d))

Rule 9 specifies the classes of persons who satisfy the means test (in addition to those specified in s 24 of the Act) for Grow Up Smiling.

 

A person satisfies the means test when:

·         the person is receiving:

-        Disability Support Pension

-        Parenting Payment

-        Special Benefit

-        Carer Payment;

·         the person, or another person on behalf of the person, is receiving financial assistance under the Veterans’ Children Education Scheme (VCES) or the Military Rehabilitation and Compensation Act Education and Training Scheme (MRCAETS), where the person is precluded from being an FTB child of an adult due to the operation of subsection 22A(1) of A New Tax System (Family Assistance) Act 1999.  In practice, this means a 16 or 17 year old in receipt of VCES or MRCAETS will be eligible;

·         with respect to the person, the person’s parent/carer/guardian is receiving:

-        Parenting Payment

-        Double Orphan Pension; or

·         the partner of the person is receiving Parenting Payment.

 

10      Issuing more than 1 voucher for a person for a calendar year (Act, ss. 27(5))

Rule 10 specifies circumstances in which the Chief Executive Medicare can issue more than one voucher to an eligible person in a calendar year.  These circumstances include when the person is an FTB-A person for more than one recipient or the voucher has been lost or damaged.

 

11      When vouchers are not required to be issued (Act, s. 29)

Rule 11 provides for the Chief Executive Medicare to not issue a voucher to an eligible patient when the patient is not assigned a Medicare number or where certain persons have not provided written consent for patient information to be used for the purpose of administering payments under the Dental Benefits Rules 2013.

 

12      Period of effect of voucher (Act, s. 31)

Rule 12 provides that for the relevant calendar year, the voucher takes effect from 1 January and stays in effect until 31 December of the calendar year. This allows a person whose eligibility is established late in the year to claim benefits for Grow Up Smiling eligible services provided earlier in the year.

 

13      Persons to whom the vouchers are to be issued (Act, paragraph 32(c))

Rule 13 specifies the persons to whom a voucher must be issued in relation to the government payment that is received by or on behalf of the eligible person.

 

14      Monetary limit on Medicare benefits (Act, paragraph 62(2)(c))

Rule 14 provides for dental benefits payable under the Rules to be capped in accordance with Schedule 3 of the Dental Benefits Schedule. Schedule 3 specifies a cap for dental benefits of $1,000 over two consecutive calendar years.  This amount will continue to apply into the future unless a new amount is provided for.  Once the cap amount is reached, no additional benefits can be paid for the specified period.

 

15      Informed Financial Consent (Act, ss. 62(2))

Rule 15 specifies for providers to obtain consent to treatment and informed financial consent before rendering any services listed in Schedule 1 of the Dental Benefits Schedule.  In order for benefits to be payable for Schedule 1 services, the consent must be recorded in writing on a ‘patient consent form’ which the patient or patient’s guardian has signed.  For those services where there has been an agreement to assign dental benefits to the provider, the provider must execute the ‘Bulk Billing Patient Consent Form’ on the first day a service is provided in each calendar year.  This will allow future bulk billed services to be provided without another consent form being signed.  Where a provider chooses not to bulk bill in relation to a service regardless of whether a ‘Bulk Billing Patient Consent Form’ has been executed  the provider must execute a ‘Non-Bulk Billing Patient Consent Form’ on each day a service is provided/

 

Rule 15 further provides for the Minister for Health to determine ‘extenuating circumstances’ in which the requirement to document the patient or guardian’s consent in a patient consent form does not apply.  Dental providers must still obtain consent even if ‘extenuating circumstances’ apply.  The Minister may require evidence that consent was received.

 

16      Clinical Records

Rule 17 specifies that providers must keep clinical records, including the patient consent form and information on tooth identification where relevant, for a period of four years. 

 

17      Limitation on number of certain services

Rule 17 places restrictions on the number of times items 88311, 88314, 88322, 88323, 88324, 88111, 88114, 88121, 88221, 88721, 88722, 88115, 88213, 88013, 88572, 88458, 88022, 88161, 88942 and 88575 can be administered to an eligible patient within specified time periods.  

 

18      Limitation on provision of certain services

Rule 18 provides that item 88012 may only be administered to eligible patients by a particular provider once every 6 months and item 88011 once every 24 months.

 

19      Limitation on Diagnostic Services

Rule 19 specifies that those diagnostic services listed in Subgroup 1 of Group 1 to the Schedule may only be administered in isolation from each other and only once per day.  This rule also provides that items 88012 and 88011 cannot both be claimed within a six month period by the same provider.

 

20      Limitation on Preventative Services

Rule 20 provides limitations on the combinations of preventative items that can be administered on the same day and also places limitations on certain preventative services provided on the same tooth on the same day as certain restorative services.

 

21      Limitation on Periodontic Services

Rule 21 precludes item 88213 from being provided on the same tooth and on the same day as item 88415.

 

22      Limitations on Oral Surgery

Rule 22 places limitations on certain oral surgery items that can be claimed in combination on the same day and limits item 88324 to multi-rooted teeth.

 

23      Limitations on Endodontic Services

Rule 23 provides limitations on the number and type of endodontic services that can be provided on the same tooth and on the same day and in some cases in relation to claiming for certain extraction and restorative services.  It also provides limitation on when item 88458 can be claimed in combination with other items.

 

24      Limitations on Restorative Services

Rule 24 provides limitations on the number and type of restorative services that can be provided on the same tooth and on the same day.

 

25      Limitations on Prosthodontic Services

Rule 25 provides limitations on the number and type of prosthodontic services that can be provided on the same tooth and on the same day.

 

26      Application of item 88455

Rule 26 provides for restrictions on when item 88455 can be provided to eligible patients.

 

27      Application of items 88521 and 88531

Rule 27 provides for restrictions on when items 88521 and 88531 can be provided to eligible patients.  It also states that preference should be given to claiming item 88531 over item 88521.

 

28      Application of item 88572

Rule 28 provides for restrictions on when item 88572 can be provided to eligible patients.

 

29      Application of item 88911

Rule 29 provides for restrictions on when item 88911 can be provided to eligible patients.

 

Schedule 1 – Dental Benefits Schedule

This Schedule sets out the item numbers, item descriptors and benefits for services for which benefits can be paid under these Rules.

 

Schedule 2 – Eligibility of Dental Services

This Schedule sets out the date after which dental services rendered by or on behalf of or under an arrangement with each State or Internal Territory are not eligible for benefits. 

 

Schedule 3 – Benefit Limits

This Schedule specifies the limit on the amount of dental benefits paid for services rendered under these Rules (cap) by the two-year period.


Statement of Compatibility with Human Rights

Prepared in accordance with Part 3 of the Human Rights (Parliamentary Scrutiny) Act 2011

 

Dental Benefits Rules 2013

 

The Dental Benefits Rules 2013 is compatible with the human rights and freedoms recognised or declared in the international instruments listed in section 3 of the Human Rights (Parliamentary Scrutiny) Act 2011.

 

Overview of the Dental Benefits Rules 2013

The Dental Benefits Rules 2013 (the Rules) repeal the former Dental Benefits Rules 2009 (the former Rules), which will in effect discontinue the Medicare Teen Dental Plan and replace it with an expanded child dental benefits schedule – Grow Up SmilingGrow Up Smiling will provide greater access to dental services for children by expanding the age range of eligibility for dental benefits, the amount of benefits payable and the scope of services available.

Human rights implications

The Rules engage the right to health and the right to social security.  Article 12(1) of the International Covenant on Economic, Social and Cultural Rights (ICESR) defines the right to health as “the right to the enjoyment of the highest attainable standard of physical and mental health.”  Article 9 of the ICESCR contains the right to social security, including social insurance.

The Rules advance the rights to health and social security by increasing access to publicly subsidised dental services for children.  Under the Medicare Teen Dental Plan, dental benefits are only payable for limited basic prevention services to eligible teenagers aged between 12-17 years.  The amount of annual dental benefits payable under this program is capped at $166.15.

However, the new Grow Up Smiling scheme will expand the Medicare Teen Dental Plan and provide greater access to services by increasing the age range of eligibility to include children aged between 2-17 years.  Grow Up Smiling will also increase the amount of dental benefits payable to a capped amount of $1,000 over two calendar years.  Eligible children will also have access to a broader range of services including both basic prevention and treatment services.  This means that a greater number of children who satisfy the eligibility criteria test will be able to access more dental benefits for a broader range of dental services than previously provided under the former Rules.

Conclusion

The Dental Benefits Rules 2013 protects and advances the rights to health and social security and is therefore compatible with Australia’s human rights obligations.

 

The Hon Tanya Plibersek MP

Minister for Health