{"id":"F2020L01302","name":"Health Insurance (Section 3C General Medical Services – Botox Injection) Determination 2020","slug":"health-insurance-section-3c-general-medical-services-botox-injection-determination-2020","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":130533,"registerId":"commonwealth-F2020L01302-current","compilationNumber":null,"startDate":"2026-04-03","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1. Name","sectionType":"section","heading":"1. Name","content":"#### 1. Name\n\n This instrument is the Health Insurance (Section 3C General Medical Services – Botox Injection) Determination 2020.","sortOrder":0},{"sectionNumber":"3. Authority","sectionType":"section","heading":"3. Authority","content":"#### 3. Authority\n\n This instrument is made under subsection 3C(1) of the Health Insurance Act 1973.","sortOrder":1},{"sectionNumber":"4. Definitions","sectionType":"section","heading":"4. Definitions","content":"#### 4. Definitions\n\n(1) In this instrument:\n\nAct means the Health Insurance Act 1973.\n\nrelevant provisions means all provisions, of the Act and regulations made under the Act, and the National Health Act 1953 and regulations made under the National Health Act 1953, relating to medical services, professional services or items.\n\nrelevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in a Schedule.\n\nSchedule means a Schedule to this instrument.\n\nNote: The following terms are defined in subsection 3(1) of the Act:\n\n clinically relevant service;\n\n general medical services table;\n\n item;\n\n professional service.\n\n(2) Unless the contrary intention appears, a reference in this instrument 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.","sortOrder":2},{"sectionNumber":"5. Treatment of relevant services","sectionType":"section","heading":"5. Treatment of relevant services","content":"#### 5. Treatment of relevant services\n\nFor subsection 3C(1) of the Act, a relevant service, provided in accordance with this instrument and as a clinically relevant service, is to be treated, for the relevant provisions, as if:\n\n(a) it were both a professional service and a medical service; and\n\n(b) there were an item in the general medical services table that:\n\ni. related to the service; and\n\nii. specified for the service a fee in relation to each State, being the fee specified in the Schedule in relation to the service.","sortOrder":3},{"sectionNumber":"6. Application of provisions of the gene","sectionType":"section","heading":"6. Application of provisions of the general medical services table","content":"#### 6. Application of provisions of the general medical services table\n\n (1) Clause 5.8.1 of the general medical services table shall have effect as if item 18361 of this Determination was specified in the clause.\n (2) Clause 5.8.2 of the general medical services table shall have effect as if item 18361 of this Determination was specified in subclause 5.8.2(1).","sortOrder":4},{"sectionNumber":"7. Indexation","sectionType":"section","heading":"7. Indexation","content":"#### 7. Indexation\n\n (1) At the start of 1 July 2025 (the indexation time), each amount covered by subsection (2) is replaced by the amount worked out using the following formula:\n ![1.024 multiplied by the amount immediately before the indexation time](image.002.png)\n Note: The indexed fees could in 2025 be viewed on the Department of Health and Aged Care’s MBS Online website (https://www.mbsonline.gov.au).\n (2) The amounts covered by this subsection are the fee for each item in a Schedule of this Determination.\n (3) An amount worked out under subsection (1) is to be rounded up or down to the nearest 5 cents (rounding down if the amount is an exact multiple of 2.5 cents).\n\nSchedule 1 – relevant services\n\n```html\n

Group T11—Botulinum toxin

Column 1

Item

Column 2

Description

Column 3

Fee ($)

18361

Clostridium Botulinum Type A Toxin‑Haemagglutinin Complex (Dysport) or Botulinum Toxin Type A Purified Neurotoxin Complex (Botox) or IncobotulinumtoxinA (Xeomin), injection of, for the treatment of moderate to severe upper limb spasticity due to cerebral palsy if:

(a) the patient is at least 2 years of age; and

(b) the treatment is for all or any of the muscles subserving one functional activity and supplied by one motor nerve, with a maximum of 4 sets of injections for the patient on any one day (with a maximum of 2 sets of injections for each upper limb), including all injections per set

(Anaes.)

145.65

\n```","sortOrder":5}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"},"flash_summary":{"complexity_score":4,"scope_assessment":{"changed":true,"description":"The Determination expands the set of services treated for Medicare/National Health Act purposes by adding item 18361 (botulinum toxin injection for upper‑limb spasticity in cerebral palsy). Concretely it creates an MBS‑style payable item with eligibility conditions (age ≥2; muscle/functional limits; max injections per day) and a specified fee ($145.65), and it directs application of relevant general medical services clauses (s5–s6) and future indexation (s7)."},"complexity_factors":["Reliance on cross‑statute and table references: instrument is made under s3C(1) of the Health Insurance Act and imports rules from the Act, its regulations and the National Health Act (s3, s4).","Definition‑dependence and dynamic scope: key concepts (eg. 'relevant service', 'clinically relevant service', 'item') are defined by reference to other statutory provisions, and the instrument adopts those provisions 'as in force from time to time' (s4(1)–(2)).","Eligibility and clinical limits encoded in a single MBS‑style item: age minimum (≥2 years), anatomical/functional scope, and maximum of 4 sets of injections per day (max 2 per upper limb) are specified in Schedule item 18361, creating detailed claimability rules.","Interaction with existing MBS clauses: the instrument makes item 18361 subject to clauses 5.8.1 and 5.8.2 of the general medical services table, affecting how anaesthesia and related provisions apply (s6).","Financial mechanics and future adjustment: a fixed fee ($145.65) is specified in the Schedule and subject to indexation on 1 July 2025 by a 1.024 multiplier with rounding rules, creating a predictable but time‑delayed adjustment (s7).","Administrative implementation and billing consequences: treating the service 'as if' an item exists in the general medical services table (s5) affects how providers claim benefits and how administrators apply existing MBS rules, even though the instrument itself is short."],"plain_english_summary":"This Determination makes a specific botulinum toxin injection for moderate–to–severe upper‑limb spasticity from cerebral palsy (patients aged 2+) a recognised service under the Health Insurance Act, sets a fee ($145.65) and limits injections per day. Mechanically, it treats that service as both a medical and professional service for the relevant Medicare/National Health Act rules and applies standard MBS indexing from 1 July 2025."},"kimi_summary":{"content_quality":"ok","complexity_score":3,"scope_assessment":{"changed":false,"description":"The legislation remains tightly focused on its original purpose: adding a single specific Botox treatment for cerebral palsy-related spasticity to the Medicare schedule. No scope creep detected."},"complexity_factors":["Single substantive item with specific clinical criteria (age threshold, muscle groups, injection limits)","Cross-references to multiple Acts (Health Insurance Act 1973, National Health Act 1953) and delegated legislation","Incorporation of external table provisions (clauses 5.8.1 and 5.8.2 of the general medical services table) by reference","Future-dated indexation mechanism with mathematical formula and rounding rules","Dense medical terminology in the Schedule description requiring clinical knowledge to interpret"],"plain_english_summary":"This adds a new Medicare item (18361) funding Botox injections for moderate–severe upper‑limb spasticity in people with cerebral palsy (age 2+), giving a $145.65 rebate per treatment and indexing fees annually from 1 July 2025. It affects patients, treating clinicians and Medicare by subsidising this specific branded treatment under set clinical and usage limits, reducing out‑of‑pocket costs."}},"importantCases":[],"_links":{"self":"/api/acts/health-insurance-section-3c-general-medical-services-botox-injection-determination-2020","history":"/api/acts/health-insurance-section-3c-general-medical-services-botox-injection-determination-2020/history","analysis":"/api/acts/health-insurance-section-3c-general-medical-services-botox-injection-determination-2020/analysis","conflicts":"/api/acts/health-insurance-section-3c-general-medical-services-botox-injection-determination-2020/conflicts","importantCases":"/api/acts/health-insurance-section-3c-general-medical-services-botox-injection-determination-2020/important-cases","documents":"/api/acts/health-insurance-section-3c-general-medical-services-botox-injection-determination-2020/documents"}}