{"id":"F2025L00583","name":"Health Insurance (Section 3C General Medical Services – Menopause and Perimenopause Health Assessment Services) Determination 2025","slug":"health-insurance-section-3c-general-medical-services-menopause-and-perimenopause-health-assessment-s","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":106382,"registerId":"commonwealth-F2025L00583-current","compilationNumber":null,"startDate":"2026-04-03","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Name","content":"#### 1 Name\n\n This instrument is the Health Insurance (Section 3C General Medical Services – Menopause and Perimenopause Health Assessment Services) Determination 2025.","sortOrder":0},{"sectionNumber":"2","sectionType":"section","heading":"Commencement","content":"#### 2 Commencement\n\n 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.\n\n```html\n

Commencement information

Column 1

Column 2

Column 3

Provisions

Commencement

Date/Details

1. The whole of this instrument

1 July 2025.

1 July 2025

\n```\n\nNote: This table relates only to the provisions of this instrument as originally made.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.\n\n 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.","sortOrder":1},{"sectionNumber":"3","sectionType":"section","heading":"Authority","content":"#### 3 Authority\n\n This instrument is made under subsection 3C(1) of the Health Insurance Act 1973","sortOrder":2},{"sectionNumber":"4","sectionType":"section","heading":"Definitions","content":"#### 4 Definitions\n\n In this instrument:\n\n> Act means the Health Insurance Act 1973.\n\n> relevant 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\n> relevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in a Schedule.\n\n> Schedule means a Schedule to this instrument.\n\n> Note: 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> 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":3},{"sectionNumber":"5","sectionType":"section","heading":"Treatment of relevant services","content":"#### 5 Treatment of relevant services\n\n> For 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> it were both a professional service and a medical service; and\n\n> there were an item in the general medical services table that:\n> \n> > related to the service; and\n> \n> > specified for the service a fee in relation to each State, being the fee specified in the Schedule in relation to the service.","sortOrder":4},{"sectionNumber":"6","sectionType":"section","heading":"Application of provisions of the general medical services table","content":"#### 6 Application of provisions of the general medical services table\n\n Clause 2.15.1 of the general medical services table shall have effect as if:\n\n item 695 is specified in subclause 2.15.1(1) for the purposes of this clause; or\n item 19000 is specified in subclause 2.15.1(2) for the purposes of this clause.\n Clause 2.15.14 of the general medical services table shall have effect as if items 695 and 19000 of this Determination were also specified in clause 2.15.14.","sortOrder":5},{"sectionNumber":"7","sectionType":"section","heading":"Application of items","content":"#### 7 Application of items\n\n Each of the services listed in Schedule 1 to this instrument applies only to a patient who:\n\n is experiencing one or more symptoms for the following, or undergoing treatment for those symptoms:\n\n> premature ovarian insufficiency;\n\n> early menopause;\n\n> perimenopause;\n\n> menopause; and\n> \n> has not received either of these services within the preceding 12 months from the date of receiving either of these services.","sortOrder":6},{"sectionNumber":"8","sectionType":"section","heading":"Repeal","content":"#### 8 Repeal\n\n This instrument is repealed at the end of 30 June 2027.","sortOrder":7},{"sectionNumber":"9","sectionType":"section","heading":"Schedules","content":"#### 9 Schedules\n\n> 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.\n\nSchedule 1 — Relevant Services\n\n```html\n

Category 1 – Professional Attendances

Group A14 — Health Assessments

Column 1

Item

Column 2

Description

Column 3

Fee ($)

695

Menopause and Perimenopause Health Assessment

Professional attendance on a patient for the assessment and management of menopause or perimenopause by a general practitioner lasting at least 20 minutes and including, but not limited to:

  1. collecting relevant information, including taking a patient history to determine pre-, peri- or post-menopausal status, patient wellbeing and contraindications for management; and
  2. undertaking a basic physical examination, including recording blood pressure, and review of height and weight; and
  3. initiating investigations and referrals as clinically indicated, with consideration given to the need for cervical screening, mammography and bone densitometry; and
  4. discussing management options including non-pharmacological and pharmacological strategies including risks and benefits;
  5. implementing a management plan which includes patient centred symptoms management; and
  6. providing the patient with preventative health care advice and information as clinically indicated, including advice on physical activity, smoking cessation, alcohol consumption, nutritional intake and weight management.

101.90

\n```\n\n```html\n

Category 1 – Professional Attendances

Group A7 – Acupuncture and Non-Specialist Practitioner Items

Subgroup 5 – Prescribed medical practitioner health assessments

Column 1

Item

Column 2

Description

Column 3

Fee ($)

19000

Menopause and Perimenopause Health Assessment

Professional attendance on a patient for the assessment and management of menopause or perimenopause by a prescribed medical practitioner lasting at least 20 minutes and including, but not limited to:

  1. collecting relevant information, including taking a patient history to determine pre-, peri- or post-menopausal status, patient wellbeing and contraindications for management; and
  2. undertaking a basic physical examination, including recording blood pressure, and review of height and weight; and
  3. initiating investigations and referrals as clinically indicated, with consideration given to the need for cervical screening, mammography and bone densitometry; and
  4. discussing management options including non-pharmacological and pharmacological strategies including risks and benefits;
  5. implementing a management plan which includes patient centred symptoms management; and
  6. providing the patient with preventative health care advice and information as clinically indicated, including advice on physical activity, smoking cessation, alcohol consumption, nutritional intake and weight management.

81.50

\n```","sortOrder":8}],"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"},"kimi_summary":{"content_quality":"ok","complexity_score":3,"scope_assessment":{"changed":false,"description":"The instrument remains tightly scoped to its original purpose. It creates two specific Medicare items for menopause/perimenopause assessments without expanding into unrelated services or creating broad regulatory frameworks. The 2027 repeal date ensures the scope remains temporary and reviewable."},"complexity_factors":["Short instrument: only 9 operative clauses plus 2 schedule tables","Minimal defined terms: only 4 definitions in clause 4, plus 4 incorporated by reference from the parent Act","Simple conditional logic: single eligibility restriction (12-month frequency rule in clause 7)","Limited cross-referencing: references to the Health Insurance Act 1973 and general medical services table, but operates as a standalone determination","Straightforward fee structure: fixed dollar amounts with no complex calculations or regional variations","Sunset provision creates certainty but no ongoing amendment complexity"],"plain_english_summary":"This creates two new Medicare rebate items (Item 695 for GPs at $101.90 and Item 19000 for other medical practitioners at $81.50) from 1 July 2025 to fund 20+ minute menopause and perimenopause health assessments. \n\nThe once‑per‑12‑months consult covers detailed history, basic exam, relevant tests/referrals, treatment options, a personalised management plan and preventive advice, addressing a prior Medicare gap in midlife women's care; the instrument expires 30 June 2027."},"flash_summary":{"complexity_score":4,"scope_assessment":{"changed":false,"description":"This instrument is narrowly focused: it creates specific Medicare items for menopause and perimenopause health assessments, sets their minimum content and fees, limits eligibility to symptomatic patients and caps frequency to once per 12 months, and is time-limited to 30 June 2027 (clauses 5–8; Schedule 1). There is no indication within the instrument that it expands beyond that single objective or repurposes other provisions; accordingly it has not grown significantly beyond its original, narrowly defined purpose."},"complexity_factors":["Short instrument (9 clauses plus Schedule) but relies on cross-references to the Health Insurance Act 1973 and the National Health Act 1953 (clause 4).","Two new items defined in Schedule 1 with multi-part clinical content and minimum time requirement (Schedule 1 items 695 and 19000).","Application and interaction with existing general medical services table provisions (clause 6 referencing clauses 2.15.1 and 2.15.14).","Eligibility constraint (symptomatic patients and once-per-12-months rule) creates a conditional claim rule (clause 7).","Temporary repeal introduces time-limited scope (clause 8).","Modest administrative complexity for implementation (mapping new items into claim and audit systems)."],"plain_english_summary":"**What this instrument does (mechanically)\n\n- Creates two new Medicare items for \"Menopause and Perimenopause Health Assessment\" that are to be treated as both professional and medical services under the Health Insurance Act 1973 (see clause 5). The items and their basic rules are set out in Schedule 1 (items 695 and 19000). \n\n- Defines the minimum consultation: a professional attendance of at least 20 minutes that includes history-taking to determine menopausal status, a basic physical exam (blood pressure, height/weight), initiation of investigations/referrals where needed, discussion of management options, preparation of a management plan and provision of preventive health advice (Schedule 1, item descriptions).\n\n- Sets the fee levels listed in the Schedule: item 695 — $101.90; item 19000 — $81.50 (Schedule 1, Column 3).\n\n- Limits eligibility: each item is claimable only for patients experiencing symptoms related to premature ovarian insufficiency, early menopause, perimenopause or menopause (or undergoing treatment for those symptoms), and only if the patient has not received either of these services in the previous 12 months (clause 7).\n\n- Applies certain provisions of the general medical services table to these items (clause 6), and treats the items as if an item had been inserted in the general medical services table specifying the stated fee for each State (clause 5).\n\n- Commences 1 July 2025 and is repealed at the end of 30 June 2027 (clauses 2 and 8). The instrument is made under subsection 3C(1) of the Health Insurance Act 1973 (clause 3).\n\n**Who this affects and how it matters\n\n- Patients: People experiencing menopausal or perimenopausal symptoms who consult a general practitioner or a \"prescribed medical practitioner\" may be eligible for a Medicare-rebated 20+ minute assessment once every 12 months (clause 7; Schedule 1).\n\n- Primary care providers: General practitioners and other \"prescribed medical practitioners\" will be able to claim these specific items (Schedule 1). That creates a discrete billing code and a set rebate/fee standard for this assessment (clauses 5 and 6, Schedule 1).\n\n- Government (Medicare): The Commonwealth becomes liable to pay benefits as if the items were in the general medical services table (clause 5). That produces identifiable program expenditure on these consultations and may drive follow-on claims for investigations or specialist services triggered by the consultation.\n\n**Why the instrument matters (stated purpose and practical effects)\n\n- Stated purpose: to enable a recognized Medicare item for a clinically relevant menopause/perimenopause health assessment so those consultations are treated and funded under the Health Insurance Act framework (clause 5; Schedule 1).\n\n- Practical effects and points to test against the stated purpose:\n - Cost and public expenditure: creating item codes with set fees (Schedule 1, Column 3) makes benefit payments traceable and likely increases Medicare outlay relative to the status quo (clause 5). There may also be second‑order cost impacts from increased referrals and investigations (Schedule 1, item content). \n - Incentives for providers: the item provides a billing pathway and a time‑based minimum (20 minutes), which may shift practice scheduling or coding toward using this specific assessment item where clinically appropriate. That changes the relative return to providing longer assessment visits (Schedule 1). \n - Patient behaviour and access: the item aims to standardise a 20+ minute assessment that includes specific actions (history, BP, management plan). It may reduce out‑of‑pocket cost for patients if providers bill at or near the Medicare schedule fee, but providers remain free to charge above the schedule creating potential co‑payments. The instrument itself does not cap practitioner billing above the schedule (clause 5 describes treatment as if an item were in the table; it does not fix private billing conduct).\n - Targeting and substitution: the once‑per‑12‑months rule (clause 7) limits frequency, reducing risk of repeated claims but may push patients to other services or private billing outside that window if more frequent care is needed.\n - Administrative/compliance effects: the instrument relies on existing general medical services table provisions (clause 6) and cross‑references the Act and National Health Act (clause 4). Practitioners and Medicare administrators must map the new items into existing claim and audit processes, and verify eligibility (symptoms and 12‑month rule). That creates modest one‑off and continuing administrative tasks.\n\n**Who pays, who decides, and likely behaviour changes\n\n- Who pays: Medicare (the Commonwealth) will pay benefits as if the items were part of the general medical services table; patients may face out‑of‑pocket costs if the practitioner charges above the schedule fee (clauses 5 and Schedule 1).\n- Who decides: clinicians determine clinical need and whether the patient meets the symptomatic eligibility in clause 7; Medicare decides benefit payment and enforcement under the Act and general medical services table rules (clauses 4–6).\n- Behaviour changes: clinicians may code more 20+ minute consultations as the new items where appropriate; patients may present specifically for a structured menopause/perimenopause assessment; referrals and investigations that are \"initiated where clinically indicated\" may increase.\n\n**Costs, trade‑offs and risks (concrete mechanisms)\n\n- Direct fiscal cost: identifiable Medicare benefit payments for the new items (clause 5; Schedule 1 fees). \n- Downstream costs: the item expressly includes initiating investigations and referrals (Schedule 1), which could increase demand for imaging, pathology, bone densitometry and specialist care paid under other programs or attracting further Medicare benefits. \n- Compliance and fraud risk: the eligibility test (symptoms and 12‑month limit, clause 7) requires clinical assessment and accurate claim coding; incorrect coding or weak documentation could generate audit exposure. \n- Implementation burden: Medicare systems, practice management software and practitioner training will need updates to include the new item numbers and to apply the 12‑month rule (clauses 5–7). \n- Distribution of benefits and costs: benefits (additional billable item) accrue narrowly to practitioners who provide these assessments and to patients who receive a rebate; costs (Medicare payments and additional downstream investigation costs) are borne by the government and partially by patients through any gap fees.\n\n**Limits and duration\n\n- The instrument is temporary — it automatically repeals 30 June 2027 (clause 8) unless extended or replaced. That limits long‑term program commitment and allows a time‑bounded test period for the new items.\n\n(References: clauses 1–9; Schedule 1 — items 695 and 19000.)"}},"importantCases":[],"_links":{"self":"/api/acts/health-insurance-section-3c-general-medical-services-menopause-and-perimenopause-health-assessment-s","history":"/api/acts/health-insurance-section-3c-general-medical-services-menopause-and-perimenopause-health-assessment-s/history","analysis":"/api/acts/health-insurance-section-3c-general-medical-services-menopause-and-perimenopause-health-assessment-s/analysis","conflicts":"/api/acts/health-insurance-section-3c-general-medical-services-menopause-and-perimenopause-health-assessment-s/conflicts","importantCases":"/api/acts/health-insurance-section-3c-general-medical-services-menopause-and-perimenopause-health-assessment-s/important-cases","documents":"/api/acts/health-insurance-section-3c-general-medical-services-menopause-and-perimenopause-health-assessment-s/documents"}}