Commonwealth Coat of Arms of Australia

Health Insurance (Optometric services) Determination 2016

 

made under subsection 3C(1) of the

 

Health Insurance Act 1973

Compilation No. 2

Compilation date:   1 July 2019

Includes amendments up to: F2019L00583

Registered:    31 July 2019

 

About this compilation

This compilation

This is a compilation of the Health Insurance (Optometric services) Determination 2016 that shows the text of the law as amended and in force on 1 July 2019 (the compilation date).

The notes at the end of this compilation (the endnotes) include information about amending laws and the amendment history of provisions of the compiled law.

Uncommenced amendments

The effect of uncommenced amendments is not shown in the text of the compiled law. Any uncommenced amendments affecting the law are accessible on the Legislation Register (www.legislation.gov.au). The details of amendments made up to, but not commenced at, the compilation date are underlined in the endnotes. For more information on any uncommenced amendments, see the series page on the Legislation Register for the compiled law.

Application, saving and transitional provisions for provisions and amendments

If the operation of a provision or amendment of the compiled law is affected by an application, saving or transitional provision that is not included in this compilation, details are included in the endnotes.

Editorial changes

For more information about any editorial changes made in this compilation, see the endnotes.

Modifications

If the compiled law is modified by another law, the compiled law operates as modified but the modification does not amend the text of the law. Accordingly, this compilation does not show the text of the compiled law as modified. For more information on any modifications, see the series page on the Legislation Register for the compiled law.

Self-repealing provisions

If a provision of the compiled law has been repealed in accordance with a provision of the law, details are included in the endnotes.

 

 

 

Contents

1. Name of Determination

3. Authority

4. Definitions

5. Treatment of relevant services

6. Application of item 10929                           4

7. Application of items 10931, 10932 and 10933      4

8. Application of items 10940 and 10941              4

9. Limitation on item 10943                            4

10. Limitation on items

11. Limitation on item 10944                            5

12. Application of items 10945 and 10946              5

13. Application of items 10945 to 10948                5

14. Professional attendance items and services provided with non-medicare services or autologous injections of blood or blood products

Schedule – relevant services

Endnotes

Endnote 3—Legislation history

Endnote 4—Amendment history

1. Name of Determination

This Determination is the Health Insurance (Optometric services) Determination 2016.

3. Authority

This Determination is made under the Health Insurance Act 1973.

4. Definitions

(1) In this Determination:

Act means the Health Insurance Act 1973.

bulk-billed for a relevant service, means:

(a) a medicare benefit is payable to a person in relation to the service; and

(b) under an agreement entered into under section 20A of the Act:

(i) the person assigns, to the person by whom the service is provided, his or her right to the payment of the medicare benefit; and

(ii) the second-mentioned person accepts the assignment in full payment of his or her fee for the service provided.

care recipient means a person receiving residential care under section 21-2 of the Aged Care Act 1997.

institution has the same meaning as in the general medical services table.

old item 10900 means item 10900 of the general medical services table as in force at any time before the repeal of the item by Part 1 of Schedule 1 to the Health Insurance Legislation Amendment (Optometric Services and Other Measures) Regulation 2014.

relevant provisions means all provisions, of the Act and regulations made under the Act, and the National Health Act 1953 and regulations made under that Act, relating to medical services, professional services or items.

relevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in the Schedule.

residential aged care facility means a facility where residential care (within the meaning given by section 41-3 of the Aged Care Act 1997) is provided.

Schedule means the Schedule to this Determination.

telehealth eligible area has the same meaning as in the general medical services table.

Note: The following terms are defined in subsection 3(1) of the Act:

 clinically relevant

 general medical services table

 optometrist

(2) In this Determination, Group A10 refers to the group of all the relevant services specified in items the Schedule, Subgroup 1 of Group A10 refers to the group of relevant services specified in items 10905 to 10944 of the Schedule and Subgroup 2 of Group A10 refers to the group of relevant services specified in items 10945 to 10948 of the Schedule.

(3) Unless the contrary intention appears, a reference in this Determination to a provision of the Act or the National Health Act 1953 or regulations made under the Act or under the National Health Act 1953 as applied, adopted or incorporated in relation to specifying a matter is a reference to those provisions as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.

5. Treatment of relevant services

 For subsection 3C(1) of the Act:

(a) a relevant service, other than the service described in item 10944, provided in accordance with this Determination and as a clinically relevant service, is to be treated, for the relevant provisions, as if:

(i) it were both a professional service and a medical service; and

(ii) there were an item in the general medical services table that:

(A) related to the service; and

(B) specified for the service a fee in relation to each State, being the fee specified in the Schedule in relation to the service.

(b) the relevant service described in item 10944, provided in accordance with this Determination and as a clinically relevant service, is to be treated, for the relevant provisions of the Act other than subsection 3(5), as if:

(i) it were both a professional service and a medical service; and

(ii) there were an item in the general medical services table that:

(A) related to the service; and

(B) specified for the service a fee in relation to each State, being the fee specified in the Schedule in relation to the service.

6. Application of item 10929

Item 10929 does not apply to a service if the patient’s requirement for contact lenses is only for any of the following reasons:

(a) because the patient does not want to wear spectacles for reasons of appearance;

(b) because the patient wants contact lenses for work or sporting purposes;

(c) because the patient has difficulty in using, or cannot use, spectacles for psychological reasons.

7. Application of items 10931, 10932 and 10933

If item 10931, 10932 or 10933 applies to a service, the fee mentioned in that item applies in addition to the fee mentioned in another item in Subgroup 1 of Group A10 that applies to the service.

8. Application of items 10940 and 10941

(1) For this section, the following are perimetry services:

(a) a service described in item 10940; 

(b) a service described in item 10941.

(2) For a particular patient, a maximum of two perimetry services apply in a 12 month period.

9. Limitation on item 10943

Item 10943 does not apply to a service used to assess learning difficulties or learning disabilities.

10. Limitation on items

(1) Item 10943 may only apply to a service in respect of a particular patient once in a 12 month period.

(2) Item 10942 may only apply to a service in respect of a particular patient twice in a 12 month period.

(3) Items 10921 to 10929 may only apply to a service in respect of a particular patient once in a 36 month period.

11. Limitation on item 10944

Item 10944 does not apply to a service on the same occasion as a service mentioned in any of items 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915, 10916 and 10918.

12. Application of items 10945 and 10946

Items 10945 and 10946 do not apply to a service if the patient or specialist travels to a place in order for the patient to satisfy the requirement in subparagraph (c)(i) of the item that, at the time of the attendance, the patient is at least 15 kilometres by road from the specialist.

13. Application of items 10945 to 10948

Items 10945 to 10948 only apply to a service if the video conferencing consultation in which the patient is participating is a service for which there is an item in the general medical services table, or treated as being in the table because of subsection 3C(1) of the Act. 

14. Professional attendance items and services provided with non-medicare services or autologous injections of blood or blood products

 

(1) Clause 1.2.4 of the general medical services table has effect as if items 10905 to 10929 were also specified in subclause 1.2.4(1).

 

(2) Clauses 1.2.7 and 1.2.8 of the general medical services table have effect as if items 10905 to 10948 were also specified in those clauses.

 

Schedule – relevant services

 

Group A10 – Optometric services provided by optometrist

Item

Service

Fee ($)

Subgroup 1 – General 

10905

Professional attendance of more than 15 minutes in duration, being the first in a course of attention, if the patient has been referred by another optometrist who is not associated with the optometrist to whom the patient is referred

67.85

10907

Professional attendance of more than 15 minutes in duration, being the first in a course of attention if the patient has attended another optometrist for an attendance to which this item or item 10905, 10910, 10911, 10912, 10913, 10914 or 10915 applies, or to which old item 10900 applied:

(a) for a patient who is less than 65 years of age—within the previous 36 months; or

(b) for a patient who is at least 65 years of age—within the previous 12 months

34.00

10910

Professional attendance of more than 15 minutes in duration, being the first in a course of attention, if:

(a) the patient is less than 65 years of age; and

(b) the patient has not, within the previous 36 months, received a service to which:

(i) this item or item 10905, 10907, 10912, 10913, 10914 or 10915 applies; or

(ii) old item 10900 applied

67.85

10911

Professional attendance of more than 15 minutes in duration,

being the first in a course of attention, if:

(a) the patient is at least 65 years of age; and

(b) the patient has not, within the previous 12 months,

received a service to which:

(i) this item, or item 10905, 10907, 10910, 10912,

10913, 10914 or 10915 applies; or

(ii) old item 10900 applied

67.85

10912

Professional attendance of more than 15 minutes in duration, being the first in a course of attention, if the patient has suffered a significant change of visual function requiring comprehensive reassessment:

(a) for a patient who is less than 65 years of age—within 36 months of an initial consultation to which:

(i) this item, or item 10905, 10907, 10910, 10913, 10914 or 10915 at the same practice applies; or

(ii) old item 10900 at the same practice applied; or

(b) for a patient who is at least 65 years of age—within 12 months of an initial consultation to which:

(i) this item, or item 10905, 10907, 10910, 10911, 10913, 10914 or 10915 at the same practice applies; or

(ii) old item 10900 at the same practice applied

67.85

10913

Professional attendance of more than 15 minutes in duration, being the first in a course of attention, if the patient has new signs or symptoms, unrelated to the earlier course of attention, requiring comprehensive reassessment:

(a) for a patient who is less than 65 years of age—within 36 months of an initial consultation to which:

(i) this item, or item 10905, 10907, 10910, 10912, 10914 or 10915 at the same practice applies; or

(ii) old item 10900 at the same practice applied; or

(b) for a patient who is at least 65 years of age—within 12 months of an initial consultation to which:

(i) this item, or item 10905, 10907, 10910, 10911, 10912, 10914 or 10915 at the same practice applies; or

(ii) old item 10900 at the same practice applied

67.85

10914

Professional attendance of more than 15 minutes in duration, being the first in a course of attention, if the patient has a progressive disorder (excluding presbyopia) requiring comprehensive reassessment:

(a) for a patient who is less than 65 years of age—within 36 months of an initial consultation to which:

(i) this item, or item 10905, 10907, 10910, 10912, 10913 or 10915 applies; or

(ii) old item 10900 applied; or

(b) for a patient who is at least 65 years of age—within 12 months of an initial consultation to which:

(i) this item, or item 10905, 10907, 10910, 10911, 10912, 10913 or 10915 applies; or

(ii) old item 10900 applied

67.85

10915

Professional attendance of more than 15 minutes in duration, being the first in a course of attention involving the examination of the eyes, with the instillation of a mydriatic, of a patient with diabetes mellitus, requiring comprehensive reassessment

67.85

10916

Professional attendance, being the first in a course of attention, of not more than 15 minutes in duration (other than a service associated with a service to which item 10931, 10932, 10933, 10940, 10941, 10942 or 10943 applies)

34.00

10918

Professional attendance, being the second or subsequent in a course of attention and being unrelated to the prescription and fitting of contact lenses (other than a service associated with a service to which item 10940 or 10941 applies)

34.00

10921

All professional attendances after the first, being those attendances regarded as a single service, in a single course of attention involving the prescription and fitting of contact lenses, being a course of attention for which the first attendance is a service to which:

(a) item 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915 or 10916 applies; or

(b) old item 10900 applied

For patients with myopia of 5.0 dioptres or greater (spherical equivalent) in one eye

168.45

10922

All professional attendances after the first, being those attendances regarded as a single service, in a single course of attention involving the prescription and fitting of contact lenses, being a course of attention for which the first attendance is a service to which:

(a) item 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915 or 10916 applies; or

(b) old item 10900 applied

For patients with manifest hyperopia of 5.0 dioptres or greater (spherical equivalent) in one eye

168.45

10923

All professional attendances after the first, being those attendances regarded as a single service, in a single course of attention involving the prescription and fitting of contact lenses, being a course of attention for which the first attendance is a service to which:

(a) item 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915 or 10916 applies; or

(b) old item 10900 applied

For patients with astigmatism of 3.0 dioptres or greater in one eye

168.45

10924

All professional attendances after the first, being those attendances regarded as a single service, in a single course of attention involving the prescription and fitting of contact lenses, being a course of attention for which the first attendance is a service to which:

(a) item 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915 or 10916 applies; or

(b) old item 10900 applied

For patients with irregular astigmatism in either eye, being a condition the existence of which has been confirmed by keratometric observation, if the maximum visual acuity obtainable with spectacle correction is worse than 0.3 logMAR (6/12) and if that corrected acuity would be improved by an additional 0.1 logMAR by the use of a contact lens

212.55

10925

All professional attendances after the first, being those attendances regarded as a single service, in a single course of attention involving the prescription and fitting of contact lenses, being a course of attention for which the first attendance is a service to which:

(a) item 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915 or 10916 applies; or

(b) old item 10900 applied

For patients with anisometropia of 3.0 dioptres or greater (difference between spherical equivalents)

168.45

10926

All professional attendances after the first, being those attendances regarded as a single service, in a single course of attention involving the prescription and fitting of contact lenses, being a course of attention for which the first attendance is a service to which:

(a) item 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915 or 10916 applies; or

(b) old item 10900 applied

For patients with corrected visual acuity of 0.7 logMAR (6/30) or worse in both eyes, being patients for whom a contact lens is prescribed as part of a telescopic system

168.45

10927

All professional attendances after the first, being those attendances regarded as a single service, in a single course of attention involving the prescription and fitting of contact lenses, being a course of attention for which the first attendance is a service to which:

(a) item 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915 or 10916 applies; or

(b) old item 10900 applied

For patients for whom a wholly or segmentally opaque contact lens is prescribed for the alleviation of dazzle, distortion or diplopia caused by pathological mydriasis, aniridia, coloboma of the iris, pupillary malformation or distortion, significant ocular deformity or corneal opacity—whether congenital, traumatic or surgical in origin

212.55

10928

All professional attendances after the first, being those attendances regarded as a single service, in a single course of attention involving the prescription and fitting of contact lenses, being a course of attention for which the first attendance is a service to which:

(a) item 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915 or 10916 applies; or

(b) old item 10900 applied

For patients who, because of physical deformity, are unable to wear spectacles

168.45

10929

All professional attendances after the first, being those attendances regarded as a single service, in a single course of attention involving the prescription and fitting of contact lenses, being a course of attention for which the first attendance is a service to which:

(a) item 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915 or 10916 applies; or

(b) old item 10900 applied

For patients who have a medical or optical condition (other than myopia, hyperopia, astigmatism, anisometropia or a condition to which item 10926, 10927 or 10928 applies) requiring the use of a contact lens for correction, if the condition is specified on the patient’s account

212.55

10930

All professional attendances regarded as a single service in a single course of attention involving the prescription and fitting of contact lenses if the patient meets the requirements of an item in the series 10921 to 10929 and requires a change in contact lens material or basic lens parameters, other than a simple power change, because of a structural or functional change in the eye or an allergic response within 36 months of the fitting of a contact lens covered by items 10921 to 10929

168.45

10931

A service to which an item in Subgroup 1 of Group A10 applies (other than this item or item 10916, 10932, 10933, 10940 or 10941), if the service:

(a) is provided:

(i) during a home visit to a person; or

(ii) in a residential aged care facility; or

(iii) in an institution; and

(b) is provided to a single patient at a single location on a single occasion; and

(c) is:

(i) bulk-billed for the fees for this item and another item in the table applying to the service; or

(ii) not bulk-billed for the fees for this item and another item in the table applying to the service

23.65

10932

A service to which an item in Subgroup 1 of Group A10 applies (other than this item or item 10916, 10931, 10933, 10940 or 10941), if the service:

(a) is provided:

(i) during a home visit to a person; or

(ii) in a residential aged care facility; or

(iii) in an institution; and

(b) is provided to each of 2 patients at a single location on a single occasion; and

(c) is:

(i) bulk-billed for the fees for this item and another item in the table applying to the service; or

(ii) not bulk-billed for the fees for this item and another item in the table applying to the service

11.80

10933

A service to which an item in Subgroup 1 of Group A10 applies (other than this item or item 10916, 10931, 10932, 10940 or 10941), if the service:

(a) is provided:

(i) during a home visit to a person; or

(ii) in a residential aged care facility; or

(iii) in an institution; and

(b) is provided to each of 3 patients at a single location on a single occasion; and

(c) is:

(i) bulk-billed for the fees for this item and another item in the table applying to the service; or

(ii) not bulk-billed for the fees for this item and another item in the table applying to the service

7.80

10940

Full quantitative computerised perimetry (automated absolute static threshold), with bilateral assessment and report, if indicated by the presence of relevant ocular disease or suspected pathology of the visual pathways or brain that:

(a) is not a service involving multifocal multichannel objective perimetry; and

(b) is performed by an optometrist;

other than a service associated with a service to which item 10916, 10918, 10931, 10932 or 10933 applies

64.75

10941

Full quantitative computerised perimetry (automated absolute static threshold) with unilateral assessment and report, if indicated by the presence of relevant ocular disease or suspected pathology of the visual pathways or brain that:

(a) is not a service involving multifocal multichannel objective perimetry; and

(b) is performed by an optometrist;

other than a service associated with a service to which item 10916, 10918 10931, 10932 or 10933 applies

39.05

10942

Testing of residual vision to provide optimum visual performance for a patient who has best corrected visual acuity of 6/15 or N.12 or worse in the better eye or a horizontal visual field of less than 120 degrees and within 10 degrees above and below the horizontal midline, involving one or more of the following:

(a) spectacle correction;

(b) determination of contrast sensitivity;

(c) determination of glare sensitivity;

(d) prescription of magnification aids;

other than a service associated with a service to which item 10916, 10921, 10922, 10923, 10924, 10925, 10926, 10927, 10928, 10929 or 10930 applies

34.00

10943

Additional testing to confirm diagnosis of, or establish a treatment regime for, a significant binocular or accommodative dysfunction, in a patient aged 3 to 14 years, including assessment of one or more of the following:

(a) accommodation;

(b) ocular motility;

(c) vergences;

(d) fusional reserves;

(e) cycloplegic refraction;

other than a service to which item 10916, 10921, 10922, 10923, 10924, 10925, 10926, 10927, 10928, 10929 or 10930 applies

34.00

10944

Cornea, complete removal of embedded foreign body from—not more than once on the same day by the same optometrist (excluding after-care)

 

Note: If the embedded foreign body is not completely removed, this item does not apply but item 10916 may apply.

73.30

Subgroup 2 – Telehealth attendance

10945

A professional attendance of less than 15 minutes (whether or not continuous) by an optometrist providing clinical support to a patient who:

(a) is participating in a video conferencing consultation with a specialist practising in the speciality of ophthalmology; and

(b) is not an admitted patient; and

(c) either:

(i) is located within a telehealth eligible area and, at the time of the attendance, is at least 15 kilometres by road from the specialist mentioned in paragraph (a); or

(ii) is a patient of an Aboriginal Medical Service, or an Aboriginal Community Controlled Health Service, for which a direction under subsection 19(2) of the Act applies

34.00

10946

A professional attendance of at least 15 minutes (whether or not continuous) by an optometrist providing clinical support to a patient who:

(a) is participating in a video conferencing consultation with a specialist practising in the speciality of ophthalmology; and

(b) is not an admitted patient; and

(c) either:

(i) is located within a telehealth eligible area and, at the time of the attendance, is at least 15 kilometres by road from the specialist mentioned in paragraph (a); or

(ii) is a patient of an Aboriginal Medical Service, or an Aboriginal Community Controlled Health Service, for which a direction under subsection 19(2) of the Act applies

67.85

10947

A professional attendance (not being a service to which any other item applies) of less than 15 minutes (whether or not continuous) by an optometrist providing clinical support to a patient who:

(a) is participating in a video conferencing consultation with a specialist practising in the speciality of ophthalmology; and

(b) at the time of the attendance, is located at a residential aged care facility (whether or not at consulting rooms situated within the facility); and

(c) is a care recipient in the facility; and

(d) is not a resident of a self-contained unit;

for an attendance on one occasion—each patient

34.00

10948

A professional attendance (not being a service to which any other item applies) of at least 15 minutes (whether or not continuous) by an optometrist providing clinical support to a patient who:

(a) is participating in a video conferencing consultation with a specialist practising in the speciality of ophthalmology; and

(b) at the time of the attendance, is located at a residential aged care facility (whether or not at consulting rooms situated within the facility); and

(c) is a care recipient in the facility; and

(d) is not a resident of a self-contained unit;

for an attendance on one occasion—each patient

67.85

 

Endnotes

Endnote 1—About the endnotes

The endnotes provide information about this compilation and the compiled law.

The following endnotes are included in every compilation:

Endnote 1—About the endnotes

Endnote 2—Abbreviation key

Endnote 3—Legislation history

Endnote 4—Amendment history

Abbreviation key—Endnote 2

The abbreviation key sets out abbreviations that may be used in the endnotes.

Legislation history and amendment history—Endnotes 3 and 4

Amending laws are annotated in the legislation history and amendment history.

The legislation history in endnote 3 provides information about each law that has amended (or will amend) the compiled law. The information includes commencement details for amending laws and details of any application, saving or transitional provisions that are not included in this compilation.

The amendment history in endnote 4 provides information about amendments at the provision (generally section or equivalent) level. It also includes information about any provision of the compiled law that has been repealed in accordance with a provision of the law.

Editorial changes

The Legislation Act 2003 authorises First Parliamentary Counsel to make editorial and presentational changes to a compiled law in preparing a compilation of the law for registration. The changes must not change the effect of the law. Editorial changes take effect from the compilation registration date.

If the compilation includes editorial changes, the endnotes include a brief outline of the changes in general terms. Full details of any changes can be obtained from the Office of Parliamentary Counsel.

Misdescribed amendments

A misdescribed amendment is an amendment that does not accurately describe the amendment to be made. If, despite the misdescription, the amendment can be given effect as intended, the amendment is incorporated into the compiled law and the abbreviation “(md)” added to the details of the amendment included in the amendment history.

If a misdescribed amendment cannot be given effect as intended, the abbreviation “(md not incorp)” is added to the details of the amendment included in the amendment history.

 

Endnote 2—Abbreviation key

 

ad = added or inserted

o = order(s)

am = amended

Ord = Ordinance

amdt = amendment

orig = original

c = clause(s)

par = paragraph(s)/subparagraph(s)

C[x] = Compilation No. x

    /sub‑subparagraph(s)

Ch = Chapter(s)

pres = present

def = definition(s)

prev = previous

Dict = Dictionary

(prev…) = previously

disallowed = disallowed by Parliament

Pt = Part(s)

Div = Division(s)

r = regulation(s)/rule(s)

ed = editorial change

reloc = relocated

exp = expires/expired or ceases/ceased to have

renum = renumbered

    effect

rep = repealed

F = Federal Register of Legislation

rs = repealed and substituted

gaz = gazette

s = section(s)/subsection(s)

LA = Legislation Act 2003

Sch = Schedule(s)

LIA = Legislative Instruments Act 2003

Sdiv = Subdivision(s)

(md) = misdescribed amendment can be given

SLI = Select Legislative Instrument

    effect

SR = Statutory Rules

(md not incorp) = misdescribed amendment

Sub‑Ch = Sub‑Chapter(s)

    cannot be given effect

SubPt = Subpart(s)

mod = modified/modification

underlining = whole or part not

No. = Number(s)

    commenced or to be commenced

 

Endnote 3—Legislation history

 

Name

Registration

Commencement

Application, saving and transitional provisions

Health Insurance (Optometric services) Determination 2016

9 March 2016 (see F2016L00285)

1 April 2016

 

Health Insurance (Section 3C – Cataract and Optometric Services) Amendment Determination 2018

13 June 2018 (F2018L00767)

1 July 2018 (s 2)

—

Health Insurance (Section 3C – Optometric Services) Amendment Determination 2019

9 Apr 2019 (F2019L00583)

1 July 2019 (s 2(1) item 1)

—

 

Endnote 4—Amendment history

 

Provision affected

How affected

Part 1

 

s 2.....................

rep LA s 48D

s 14....................

am F2018L00767

Schedule

 

Schedule.................

am F2019L00583