{"id":"F2020L01351","name":"Health Insurance (Section 3C General Medical Services – Extracorporeal Photopheresis) Determination 2020","slug":"health-insurance-section-3c-general-medical-services-extracorporeal-photopheresis-determination-2020","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":130569,"registerId":"commonwealth-F2020L01351-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 – Extracorporeal Photopheresis) 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\nPharmaceutical Benefits Scheme means the scheme for the supply of pharmaceutical benefits established under Part VII of the National Health Act 1953.\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\nTreatment cycle for a patient, means a single day of treatment, or consecutive days of treatment that is required to deliver extracorporeal photopheresis.\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 1.2.6 of the general medical services table shall have effect as if items 14247 and 14249 of this Determination were also specified in the clause.\n\n (2) Clause 1.2.7 of the general medical services table shall have effect as if items 14247 and 14249 of this Determination were also specified in the clause.\n\n (3) Clause 1.2.9 of the general medical services table shall have effect as if items 14247 and 14249 of this Determination were specified in the clause.\n\n (4) Clause 1.2.10 of the general medical services table shall have effect as if items 14247 and 14249 of this Determination were specified in the clause.\n\n (5) Clause 5.1.1 of the general medical services table shall have effect as if items 14247 and 14249 of this Determination were specified in the clause.","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\n (2) The amounts covered by this subsection are the fee for each item in a Schedule of this Determination.\n\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 T1—Miscellaneous therapeutic procedures

Subgroup 13 – Miscellaneous therapeutic procedures

Column 1

Item

Column 2

Description

Column 3

Fee ($)

14247

Extracorporeal photopheresis for the treatment of erythrodermic stage III‑IVa T4 M0 cutaneous T‑cell lymphoma; if

(a) the service is provided in the initial six months of treatment; and

(b) the service is delivered using an integrated, closed extracorporeal photopheresis system; and

(c) the patient is 18 years old or over; and

(d) the patient has received prior systemic treatment for this condition and experienced either disease progression or unacceptable toxicity while on this treatment; and

(e) the service is provided in combination with the use of Pharmaceutical Benefits Scheme‑subsidised methoxsalen; and

(f) the service is supervised by a specialist or consultant physician in the speciality of haematology.

Applicable once per treatment cycle (H)

1,925.55

14249

Extracorporeal photopheresis for the continuing treatment of erythrodermic stage III‑IVa T4 M0 cutaneous T‑cell lymphoma; if

(a) in the preceding 6 months:

(i) a service to which item 14247 applies has been provided; and

(ii) the patient has demonstrated a response to this service; and

(iii) the patient requires further treatment; and

(b) the service is delivered using an integrated, closed extracorporeal photopheresis system; and

(c) the patient is 18 years old or over; and

(d) the service is provided in combination with the use of Pharmaceutical Benefits Scheme‑subsidised methoxsalen; and

(e) the service is supervised by a specialist or consultant physician in the speciality of haematology.

Applicable once per treatment cycle (H)

1,925.55

\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":"This instrument expands the MBS by adding two specific items for extracorporeal photopheresis (Schedule items 14247 and 14249) and treats those services as both professional and medical services for the relevant provisions of the Health Insurance Act (s5, Schedule). It sets a uniform fee of $1,925.55 per treatment cycle (Schedule) and an indexation rule effective 1 July 2025 (cl.7). Coverage is narrowly targeted by clinical, device and supervision conditions (Schedule), and the Determination also brings those items within multiple clauses of the general medical services table (cl.6), thereby changing which existing billing, eligibility and documentation rules apply. Medicare (the payer under the Act) will reimburse only when the specified conditions and documentation are met, creating identifiable compliance and verification obligations for providers (Schedule; cl.7)."},"complexity_factors":["Cross‑references to the Health Insurance Act 1973, the National Health Act 1953 and the general medical services table (requires understanding of how MBS items integrate with other provisions).","Detailed clinical eligibility criteria in the Schedule (disease stage, prior systemic treatment and response, adult patients) which require medical documentation to verify eligibility (Schedule items 14247, 14249).","Operational delivery constraints: requirement for an integrated, closed extracorporeal photopheresis system and specialist/consultant haematologist supervision (Schedule).","Interplay with the Pharmaceutical Benefits Scheme (PBS): treatment must be provided in combination with PBS‑subsidised methoxsalen (Schedule).","Modification of existing general medical services table clauses (clause 6) so items are subject to multiple pre‑existing rules (1.2.6, 1.2.7, 1.2.9, 1.2.10, 5.1.1).","Indexation mechanism (clause 7): a specified multiplier from 1 July 2025, plus a rounding rule to the nearest 5 cents, which affects future fee amounts and accounting.","Per‑treatment‑cycle application and identical fee for initial and continuing treatment items (billing frequency and recordkeeping implications).","Administrative compliance burden on providers to evidence prior treatments, demonstrated response and need for continuing treatment (continuing treatment item conditions)."],"plain_english_summary":"This Determination adds two Medicare Benefits Schedule (MBS) items for extracorporeal photopheresis to treat advanced cutaneous T‑cell lymphoma, sets a per‑treatment‑cycle fee ($1,925.55) and prescribes clinical and delivery requirements (adult patients, integrated closed system, prior systemic treatment, PBS‑subsidised methoxsalen, specialist haematologist supervision). It treats the service as both a medical and professional service for the Health Insurance Act (s5, Schedule). Medicare will reimburse subject to those eligibility, device and supervision conditions and the fees are indexed from 1 July 2025 (cl.7)."},"kimi_summary":{"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"The legislation remains tightly focused on its original purpose: establishing Medicare rebates for extracorporeal photopheresis treatment of a specific lymphoma type. The scope has not expanded beyond this narrow therapeutic indication."},"complexity_factors":["Multiple cross-references to the Health Insurance Act 1973 and National Health Act 1953 (including dynamic 'as in force from time to time' references)","Six specific eligibility conditions for Item 14247, including nested sub-conditions for Item 14249 (preceding 6-month response requirement with three sub-bullets)","Technical medical terminology requiring specialist knowledge (erythrodermic stage III-IVa T4 M0 cutaneous T-cell lymphoma, extracorporeal photopheresis, methoxsalen)","Incorporation by reference of five separate clauses from the general medical services table (clauses 1.2.6, 1.2.7, 1.2.9, 1.2.10, and 5.1.1)","Mathematical indexation formula with rounding rules (nearest 5 cents, specific tie-breaker for 2.5 cent multiples)","Defined term 'treatment cycle' that collapses consecutive treatment days into a single billing unit"],"plain_english_summary":"This determination adds extracorporeal photopheresis to Medicare, making a specialised blood-and-light treatment for advanced erythrodermic cutaneous T‑cell lymphoma eligible for government rebates. It applies to adult patients who have failed other systemic therapies and receive care under haematologist supervision using a closed system and PBS‑subsidised methoxsalen.\n\nBy covering a previously out‑of‑pocket procedure (about $1,925 per treatment), the measure improves access to a life‑extending option; fees will rise with inflation from 1 July 2025."}},"importantCases":[],"_links":{"self":"/api/acts/health-insurance-section-3c-general-medical-services-extracorporeal-photopheresis-determination-2020","history":"/api/acts/health-insurance-section-3c-general-medical-services-extracorporeal-photopheresis-determination-2020/history","analysis":"/api/acts/health-insurance-section-3c-general-medical-services-extracorporeal-photopheresis-determination-2020/analysis","conflicts":"/api/acts/health-insurance-section-3c-general-medical-services-extracorporeal-photopheresis-determination-2020/conflicts","importantCases":"/api/acts/health-insurance-section-3c-general-medical-services-extracorporeal-photopheresis-determination-2020/important-cases","documents":"/api/acts/health-insurance-section-3c-general-medical-services-extracorporeal-photopheresis-determination-2020/documents"}}