Health Insurance Amendment (Assignment of Medicare Benefits and Other Measures) Regulations 2025
I, the Honourable Sam Mostyn AC, Governor‑General of the Commonwealth of Australia, acting with the advice of the Federal Executive Council, make the following regulations.
Dated 21 August 2025
Sam Mostyn AC
Governor‑General
By Her Excellency’s Command
Mark Butler
Minister for Health and Ageing
1 Name
2 Commencement
3 Authority
4 Schedules
Schedule 1—Amendments
Part 1—Main amendments
Health Insurance Regulations 2018
Part 2—Other amendments
Health Insurance Regulations 2018
Part 3—Application, saving and transitional provisions
Health Insurance Regulations 2018
This instrument is the Health Insurance Amendment (Assignment of Medicare Benefits and Other Measures) Regulations 2025.
(1) Each provision of this instrument 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. The whole of this instrument | Immediately after the commencement of Schedule 1 to the Health Insurance Legislation Amendment (Assignment of Medicare Benefits) Act 2024. |
|
Note: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.
(2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.
This instrument is made under the Health Insurance Act 1973.
Each instrument that is specified in a Schedule to this instrument is amended or repealed as set out in the applicable items in the Schedule concerned, and any other item in a Schedule to this instrument has effect according to its terms.
1 Section 4
Insert:
episodic agreement: see subsection 65C(2).
episodic post‑agreement: see paragraph 65C(3)(b).
episodic pre‑agreement: see paragraph 65C(3)(a).
2 After Division 7 of Part 3
Insert:
Under subsection 20A(1) of the Act, an eligible person to whom a medicare benefit is or will be payable in respect of a professional service may, in certain circumstances, enter into an agreement to assign the right to the payment of the medicare benefit. These are bulk billing assignments. Subdivision B of this Division sets out requirements that must be met for bulk billing assignment agreements.
Subsection 20A(2) of the Act provides that, in certain circumstances, an eligible person who holds a complying health insurance policy with a private health insurer may be taken to have assigned the right to payment of medicare benefit. These are simplified billing assignments. Subdivision C of this Division sets out requirements that, if met, form part of those circumstances indicating that the person is taken to have assigned the right to the benefit.
For the purposes of paragraph 20A(1)(d) of the Act, the agreement must be an episodic agreement that meets the requirements specified in section 65C of this instrument.
(1) For the purposes of section 65B, this section specifies the requirements that must be met in relation to an episodic agreement.
(2) An episodic agreement is an agreement under subsection 20A(1) of the Act, entered into either before or after a particular professional service (the agreement service) is rendered, that provides that the assignor assigns the assignor’s right to the payment of medicare benefit payable in respect of that professional service to the professional.
Note: The agreement may also provide that the assignor’s right to the payment of medicare benefit payable in respect of other professional services that are not described in the agreement is assigned: see paragraph (c) of column 2 of items 1 and 3 in the table in subsection (4).
(3) There are 2 types of episodic agreement:
(a) an episodic pre‑agreement, which is an episodic agreement that is entered into before the agreement service is rendered; and
(b) an episodic post‑agreement, which is an episodic agreement that neither party offers entry into until after the agreement service is rendered.
(4) The professional must ensure that the assignor is given the following information, in writing, before or at the time either party offers entry into an episodic agreement:
(a) the name of the person to whom the agreement service is or will be rendered;
(b) the date on which the agreement is proposed to be entered into;
(c) whether the agreement is an episodic pre‑agreement or an episodic post‑agreement;
(d) for an agreement of a kind referred to in column 1 of an item in the following table—the information mentioned in column 2 of the item.
Information that must be given to assignor | ||
Item | Column 1 Kind of agreement | Column 2 Information |
1 | Episodic pre‑agreement relating to an agreement service that is a pathology service (other than a service specified in an item in Group P9 of the pathology services table) | The following: (a) the date on which the specimen in relation to which the agreement service will be rendered is or was collected; (b) a description of the agreement service in terms or symbols that: (i) would be generally understood by medical practitioners; and (ii) are sufficient to identify the item in the pathology services table that specifies the service; (c) a statement to the effect that entry into the agreement also constitutes the assignor’s agreement to assign to the professional the assignor’s right to the payment of medicare benefit in respect of a pathologist‑determinable service that is not described in the agreement, if: (i) the professional is the approved pathology practitioner who will render, or on whose behalf will be rendered, the service; and (ii) the professional determines that the service is necessary |
2 | Episodic post‑agreement relating to an agreement service that is a pathology service (other than a service specified in an item in Group P9 of the pathology services table) | The following: (a) the particulars prescribed in subsection 54(2), relating to the agreement service; (b) the date on which the specimen in relation to which the agreement service was rendered was collected; (c) the number of the item in the pathology services table that specifies the agreement service |
3 | Episodic pre‑agreement relating to an agreement service that is a diagnostic imaging service | The following: (a) the date on which the diagnostic imaging procedure to be used in rendering the agreement service is undertaken; (b) a description of the agreement service sufficient to identify the item in the diagnostic imaging services table that specifies the service; (c) if the agreement service is an R‑type diagnostic imaging service—a statement to the effect that entry into the agreement also constitutes the assignor’s agreement to assign to the professional the assignor’s right to the payment of medicare benefit in respect of a diagnostic imaging service that is not described in the agreement, if the professional is the providing practitioner (within the meaning of section 16B of the Act) and: (i) the professional has formed the opinion that the service is necessary based on the results of the rendering of the agreement service; or (ii) the professional has formed the opinion that the service is more appropriate in the diagnosis of the condition of the person to whom the service will be rendered than the agreement service, being an opinion that would be accepted by the general body of specialists or consultant physicians in the specialty practised by the professional |
4 | Episodic post‑agreement relating to an agreement service that is a diagnostic imaging service | The following: (a) the identifying details of the professional (see subsection (5)); (b) the date on which the diagnostic imaging procedure used in rendering the agreement service was undertaken; (c) the number of the item in the diagnostic imaging services table that specifies the agreement service |
5 | Episodic pre‑agreement relating to an agreement service not covered by items 1 to 4 in this table | The following: (a) the identifying details of the professional (see subsection (5)); (b) the date on which the agreement service will be rendered; (c) the basic description of the agreement service, as set out in the Health Insurance Regulations 2018 ‑ Basic Service Description for Assignment of Medicare Benefits, as existing on the day the Health Insurance Amendment (Assignment of Medicare Benefits and Other Measures) Regulations 2025 commences |
6 | Episodic post‑agreement relating to an agreement service not covered by items 1 to 4 in this table | The following: (a) the identifying details of the professional (see subsection (5)); (b) the date on which the agreement service is rendered; (c) the number of the item in the general medical services table or the pathology services table that specifies the agreement service |
(5) For the purposes of items 4 to 6 in the table in subsection (4), the identifying details of the professional are:
(a) the name of the professional and the address of the place of practice from which the professional is, or expects to be, practising at the time the agreement service is rendered; or
(b) the provider number allocated to the professional in respect of:
(i) the place of practice from which the professional is, or expects to be, practising at the time the agreement service is rendered; or
(ii) if subparagraph (i) does not apply—any place of practice.
(6) The agreement must:
(a) include the information that was required to be given to the assignor in accordance with subsection (4); and
(b) specify whether the assignor is the person to whom the agreement service is or will be rendered; and
(c) be a written document; and
(d) be signed by the assignor.
Information that must be given before request is made
(1) For the purposes of paragraph 20AAA(3)(d) of the Act, the responsible provider must give, or cause to be given, the following information, in writing, to the assignor before a request under paragraph 20AAA(3)(a) of the Act is made in relation to the medicare benefit in respect of a professional service:
(a) the name of the person to whom the professional service was or will be rendered;
(b) in relation to the complying health insurance policy that covers (wholly or partly) the assignor’s liability to pay fees and charges in respect of the professional service:
(i) the name of the private health insurer; and
(ii) the membership number or other unique identifier allocated by the insurer to the person to whom the professional service was or will be rendered;
(c) that the request would be made to the following person:
(i) in the case of hospital treatment authorised by the operator of a hospital—the operator of the hospital;
(ii) in the case of hospital‑substitute treatment authorised by an organization—the organization;
(iii) in the case of hospital‑substitute treatment to which subparagraph (ii) does not apply—the professional;
(d) the information specified in subsection (2);
(e) either:
(i) if the professional service was or will be rendered while hospital treatment requiring a hospital admission is provided—the date of admission; or
(ii) otherwise—the date on which the professional service was or will be rendered;
(f) a description of the hospital treatment or hospital‑substitute treatment during which the professional service was or will be rendered;
(g) the name of the person to whom the right to payment of the medicare benefit will be taken to be assigned, as specified in subsection 20AAA(4) of the Act;
(h) either:
(i) if the professional service was or will be rendered in a hospital—the name of the hospital; or
(ii) if the professional service was or will be rendered in a private residence—a statement to that effect; or
(iii) if neither subparagraph (i) nor (ii) apply—the address at which the professional service was or will be rendered.
(2) For the purposes of paragraph (1)(d), the information is as follows:
(a) if the request would be made to the operator of a hospital or an organization—either:
(i) the name of each professional who wishes to be covered by the request, being a professional who is authorised by the operator of the hospital or the organization (as the case may be) to provide the hospital treatment or hospital‑substitute treatment during which the professional service was or will be rendered; or
(ii) a statement that the professional service may be rendered by, or on behalf of, any person who is authorised by the operator of the hospital or the organization (as the case may be) to provide the hospital treatment or hospital‑substitute treatment during which the professional service was or will be rendered;
(b) if the request would be made to a professional—the name of the professional.
Note: For the purposes of subparagraph (a)(i), the hospital treatment or hospital‑substitute treatment may be provided by a named professional directly, or under a named professional’s management or control: see subsection 20AAA(7) of the Act.
Making a request
(3) For the purposes of paragraph 20AAA(3)(a) of the Act, the request:
(a) must include the information that was required to be given to the assignor in accordance with subsection (1) of this section; and
(b) must be made in writing; and
(c) must be made before or as soon as practicable after the professional service is rendered.
Modifying a request
(4) For the purposes of paragraph 20AAA(3)(b) of the Act, if, after a professional service is rendered, the responsible provider or a person authorised by the responsible provider intends to modify a request, the responsible provider must:
(a) give the assignor, in writing, a revised version of the information that must be given under subsection (1) of this section that accounts for the proposed modification; and
(b) obtain the assignor’s written approval to so modify the request.
Note: If the assignor does not approve the modification, the assignor’s right to payment of a medicare benefit is only taken to be assigned under subsection 20A(2) of the Act in relation to a medicare benefit covered by the original request.
(5) The modification:
(a) must be made in writing; and
(b) must only be made in circumstances in which the original request does not cover the medicare benefit in respect of a professional service (the new professional service) rendered to the eligible person:
(i) if the professional service covered by the original request was to be rendered while hospital treatment requiring a hospital admission is provided—during that hospital treatment; or
(ii) otherwise—on the date on which the professional service covered by the original request was to be rendered; and
(c) must cover the new professional service; and
(d) must be made as soon as practicable after the new professional service has been rendered.
For the purposes of paragraph 20B(1)(a) of the Act, a claim for a medicare benefit in respect of a professional service must include the following:
(a) the particulars prescribed under subsection 19(6) of the Act in relation to professional services generally;
(b) any particulars prescribed under that subsection in relation to each class of professional services in which the professional service is included;
(c) if the claim is made on the basis that the right to payment of the medicare benefit is taken to be assigned under subsection 20A(2) of the Act—a declaration, by the person making the claim, that paragraphs 20A(2)(a) to (c) and (e) of the Act are satisfied.
3 Before Division 1 of Part 11
Insert:
For the purposes of subsection 127A(1) of the Act, the kind of record that must be kept by a professional who:
(a) enters into an agreement, under subsection 20A(1) of the Act, to assign a medicare benefit in respect of a professional service; and
(b) makes a claim for the medicare benefit, in accordance with the agreement, under section 20B of the Act;
is a copy of the agreement.
Notification of payment of medicare benefit
(1) For the purposes of subparagraph 127(3)(d)(i) of the Act, the insurer or approved billing agent must give the assignor a notification of the payment of the medicare benefit to the insurer or approved billing agent (as the case may be).
(2) The notification must include the following:
(a) the name of the person to whom the professional service, in respect of which the assignor is taken to have assigned the medicare benefit, was rendered;
(b) in relation to the complying health insurance policy that covered (wholly or partly) the assignor’s liability to pay fees and charges in respect of the professional service:
(i) the name of the private health insurer; and
(ii) the membership number or other unique identifier allocated by the insurer to the person to whom the professional service was rendered;
(c) the name of the professional who rendered, or on whose behalf was rendered, the professional service;
(d) the date on which the professional service was rendered;
(e) the number of the item that specifies the professional service;
(f) the amount of medicare benefit paid;
(g) the name of the insurer or approved billing agent (as the case may be).
Notification of modification of request
(3) For the purposes of subparagraph 127(5)(d)(i) of the Act, the responsible provider must give the assignor a notification of the modification of the request.
Manner and form of notification
(4) A notification under this section must be given to the assignor:
(a) in writing; and
(b) in the manner agreed by the assignor.
Private health insurer
(1) For the purposes of subsection 127A(1) of the Act, if, under subsection 20A(2) of the Act, the right to payment of a medicare benefit in respect of a professional service is taken to be assigned to an insurer, the kinds of records that must be kept by the insurer are as follows:
(a) a copy of the complying health insurance policy under which the assignor is covered (wholly or partly) for liability to pay fees and charges in respect of the professional service;
(b) a copy of the notification that the insurer is required to give the assignor under paragraph 127(3)(d) of the Act;
(c) if subsection 20AAA(1) of the Act applies to the assignor’s right to the payment of the medicare benefit in respect of the professional service—records of the arrangement, mentioned in paragraph (a) of that subsection, under which the insurer made, or is required to make, a payment in relation to the rendering of the professional service.
Approved billing agent
(2) For the purposes of subsection 127A(1) of the Act, if, under subsection 20A(2) of the Act, the right to payment of a medicare benefit in respect of a professional service is taken to be assigned to an approved billing agent, the kinds of records that must be kept by the billing agent are as follows:
(a) records of the complying health insurance policy under which the assignor is covered (wholly or partly) for liability to pay fees and charges in respect of the professional service;
(b) a copy of the notification that the billing agent is required to give the assignor under paragraph 127(3)(d) of the Act.
Operator of the hospital
(3) Subsection (4) applies to an operator of a hospital if
(a) under subsection 20A(2) of the Act, the assignor’s right to the payment of the medicare benefit in respect of a professional service is taken to be assigned; and
(b) the professional service is rendered while hospital treatment authorised by the operator of the hospital is provided.
(4) For the purposes of subsection 127A(3) of the Act, the kinds of records that must be kept by the operator of the hospital are as follows:
(a) records of the authorisation to provide the hospital treatment (see subsection 20AAA(7) of the Act);
(b) if subsection 20AAA(1) of the Act applies to the assignor’s right and the insurer made, or is required to make, a payment in relation to the rendering of the professional service under an arrangement with the operator of the hospital:
(i) a copy of that arrangement; and
(ii) a copy of the arrangement, under which treatment is provided to persons insured by the insurer, between the operator of the hospital and the professional who rendered, or on whose behalf was rendered, the professional service;
(c) if subsection 20AAA(3) of the Act applies to the assignor’s right and the assignor made a request to the operator of the hospital for the purposes of paragraph (a) of that subsection:
(i) a copy of the request; and
(ii) a copy of any modification to the request; and
(iii) a copy of the assignor’s written approval of any such modification; and
(iv) records of any notification that the operator of the hospital is required to give the assignor under paragraph 127(5)(d) of the Act;
(d) if subsection 20AAA(5) of the Act applies to the assignor’s right in respect of the professional service (the secondary professional service) and subsection 20AAA(1) or (3) of the Act applies to the assignor’s right in respect of another professional service (the related professional service) rendered while the hospital treatment mentioned in paragraph (3)(b) of this section is provided—a record of evidence that the secondary professional service:
(i) was rendered for a complication that arose during the related professional service; or
(ii) was unplanned but was rendered during planned treatment of which the related professional service was part, and was, in the view of the professional who rendered or on whose behalf was rendered the secondary professional service, necessary and urgent.
Organization
(5) Subsection (6) applies to an organization if:
(a) under subsection 20A(2) of the Act, the assignor’s right to the payment of the medicare benefit in respect of a professional service is taken to be assigned; and
(b) the professional service is rendered while hospital‑substitute treatment authorised by the organization is provided.
(6) For the purposes of subsection 127A(3) of the Act, the kinds of records that must be kept by the organization are as follows:
(a) records of the authorisation to provide the hospital‑substitute treatment (see subsection 20AAA(7) of the Act);
(b) if subsection 20AAA(1) of the Act applies to the assignor’s right and the insurer made, or is required to make, a payment in relation to the rendering of the professional service under an arrangement with the organization:
(i) a copy of that arrangement; and
(ii) a copy of the arrangement, under which treatment is provided to persons insured by the insurer, between the organization and the professional who rendered, or on whose behalf was rendered, the professional service;
(c) if subsection 20AAA(3) of the Act applies to the assignor’s right and the assignor made a request to the organization for the purposes of paragraph (a) of that subsection:
(i) a copy of the request; and
(ii) a copy of any modification to the request; and
(iii) a copy of the assignor’s written approval of any such modification; and
(iv) records of any notification that the organization is required to give the assignor under paragraph 127(5)(d) of the Act;
(d) if subsection 20AAA(5) of the Act applies to the assignor’s right in respect of the professional service (the secondary professional service) and subsection 20AAA(1) or (3) of the Act applies to the assignor’s right in respect of another professional service (the related professional service) rendered while the hospital‑substitute treatment mentioned in paragraph (5)(b) of this section is provided—a record of evidence that the secondary professional service:
(i) was rendered for a complication that arose during the related professional service; or
(ii) was unplanned but was rendered during planned treatment of which the related professional service was part, and was, in the view of the professional who rendered or on whose behalf was rendered the secondary professional service, necessary and urgent.
Professional
(7) Subsection (8) applies to a professional if:
(a) under subsection 20A(2) of the Act, the assignor’s right to the payment of the medicare benefit in respect of a professional service is taken to be assigned; and
(b) the professional service is rendered while hospital‑substitute treatment to which paragraph 127A(3)(b) of the Act does not apply is provided.
(8) For the purposes of subsection 127A(3) of the Act, the kinds of records that must be kept by the professional are as follows:
(a) if subsection 20AAA(1) of the Act applies to the assignor’s right and the insurer made, or is required to make, a payment in relation to the rendering of the professional service under an arrangement with the professional—a copy of that arrangement;
(b) if subsection 20AAA(3) of the Act applies to the assignor’s right and the assignor made a request to the professional for the purposes of paragraph (a) of that subsection:
(i) a copy of the request; and
(ii) a copy of any modification to the request; and
(iii) a copy of the assignor’s written approval of any such modification; and
(iv) records of any notification that the professional is required to give the assignor under paragraph 127(5)(d) of the Act;
(c) if subsection 20AAA(5) of the Act applies to the assignor’s right in respect of the professional service (the secondary professional service) and subsection 20AAA(1) or (3) of the Act applies to the assignor’s right in respect of another professional service (the related professional service) rendered while the hospital‑substitute treatment mentioned in paragraph (7)(b) of this section is provided—a record of evidence that the secondary professional service:
(i) was rendered for a complication that arose during the related professional service; or
(ii) was unplanned but was rendered during planned treatment of which the related professional service was part, and was, in the view of the professional who rendered or on whose behalf was rendered the secondary professional service, necessary and urgent.
For the purposes of paragraph 127A(5)(c) of the Act, for a record of a kind specified in column 1 of an item in the following table, the day mentioned in column 2 of the item is specified.
Item | Column 1 Kind of record | Column 2 Retention day |
1 | Records, or a copy, of a complying health insurance policy | The day that is 7 years after the day the policy ceases to be in force |
2 | Records, or a copy, of an arrangement mentioned in paragraph 20AAA(1)(a) of the Act | The day that is 7 years after the day the arrangement ceases to be in force |
3 | A copy of a request made for the purposes of paragraph 20AAA(3)(a) of the Act | The day that is 7 years after the day the request was made |
4 | A copy of a modification to such a request and the assignor’s written approval of the modification | The day that is 7 years after the day the request was so modified |
5 | Either: (a) a copy of a notification required to be given under paragraph 127(3)(d) of the Act; or (b) records of a notification required to be given under paragraph 127(5)(d) of the Act | The day that is 7 years after the day the notification was given |
6 | A record of evidence that a secondary professional service (within the meaning of paragraphs 89C(4)(d), (6)(d) and (8)(c)): (a) was rendered for a complication that arose during the related professional service; or (b) was unplanned but was rendered during planned treatment of which the related professional service was part, and was, in the view of the professional who rendered or on whose behalf was rendered the secondary professional service, necessary and urgent | The day that is 7 years after the day the evidence was created |
4 Division 5 of Part 3 (heading)
Repeal the heading, substitute:
5 Section 47
Omit all the words from and including “on:” to and including “in relation to the professional service”.
6 Section 47
Omit “particulars for the purposes of subsection 19(6) of the Act”, substitute “those particulars”.
7 In the appropriate position in Part 12
Insert:
In this Division:
commencement day means the day this Division commences.
(1) This section applies if:
(a) before the commencement day, an eligible person made an offer under subsection 20A(2) of the Act to enter into an agreement under subsection 20A(1) of the Act with respect to the medicare benefit payable in respect of a pathology service; and
(b) on or after the commencement day, a person by whom, or on whose behalf, the pathology service will be rendered accepts the offer.
(2) Despite section 65B of this instrument, the agreement does not need to meet the requirements specified in subsection 65C(4) of this instrument.
(3) The agreement may:
(a) despite paragraph 65C(6)(a) of this instrument, include only so much of the information that is, on and after the commencement day, required to be given to an assignor under subsection 65C(4) of this instrument as was actually given to the eligible person before the person made the offer; and
(b) despite paragraph 65C(6)(b) of this instrument, omit to specify whether the eligible person is the person to whom the pathology service will be rendered.