Commonwealth act

Health Insurance Act 1973

In ForceCTH

Jurisdiction

Commonwealth

Act Number

42 of 1974

Collection

act

Plain English Summary

9/10 complexity

The Health Insurance Act 1973 creates and governs Medicare, Australia’s universal health insurance scheme. It determines who’s eligible, which health services attract government rebates, and the rules for qualified providers and approved pathology/imaging services.

It also sets protections against fraud, mechanisms to limit patient out‑of‑pocket exposure through safety nets, and workforce obligations for some government‑funded medical trainees — so it directly shapes how much individuals and families pay and who can claim benefits.

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Deep Dive

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What it does

The Health Insurance Act 1973 establishes Medicare benefit entitlement for professional services rendered in Australia to eligible persons, calculated by reference to prescribed tables of fees and items (ss 9, 10). Part I sets out commencement, definitions and ministerial powers to prescribe tables, recognise specialists, accredit podiatrists and treat unspecified services as professional services (ss 1-4B, 3AAA-3GC). Part IIA regulates pathology through approved pathology practitioner and authority undertakings, accredited laboratories, specimen collection centres and request retention (ss 23DC-23DNL). Part IIB requires written requests for R-type diagnostic imaging services, registration of premises and bases on the Diagnostic Imaging Register, and accreditation schemes (ss 16B, 23DZK-23DZZIAG). Part IIC mirrors registration requirements for radiation oncology premises and bases (ss 23DZZJ-23DZZZH). Part IIBA prohibits non-permitted benefits and threats intended to induce pathology or diagnostic imaging requests (ss 23DZZIA-23DZZIU). Part VAA creates the Professional Services Review Scheme to examine inappropriate practice (ss 79A-106ZR). Parts IV, IVAA and VA authorise health program grants, former Health and Hospitals Fund payments and the National Rural Health Commissioner. Section 20AA voids PPSA security interests in assigned benefits. Part II (ss 9-10ADA) establishes Medicare benefits payable for professional services rendered in Australia to eligible persons, calculated by reference to the general medical services table, pathology services table and diagnostic imaging services table. Part IIB (ss 16B-16G) and Part IIA (ss 16A, 23DC-23DL) impose request, registration and accreditation requirements for R-type diagnostic imaging services and pathology services. Part VAA (ss 79A-106ZR) creates the Professional Services Review Scheme to review and investigate provision of services for inappropriate practice, with outcomes including agreements under s 92, Committee referrals under s 93 and determinations under s 106U. Parts IIC, IV, IVAA and VA address radiation oncology registration, health program grants and the National Rural Health Commissioner.

Current sections

Direct links to the current provisions in Health Insurance Act 1973.

406

Part I

Preliminary

Part I—Preliminary

Short title

1 Short title

This Act may be cited as the Health Insurance Act 1973.

Commencement

2 Commencement

This Act shall come into operation on the day on which it receives the Royal Assent.

Interpretation

3 Interpretation

(1) In this Act, unless the contrary intention appears:

ABN has the meaning given by section 41 of the A New Tax System (Australian Business Number) Act 1999.

accredited pathology laboratory means premises in respect of which there is in force an approval under section 23DN.

accredited podiatrist means a podiatrist who is accredited by the Minister in writing under section 3AAA.

approved accreditor has the meaning given by paragraph 23DZZIAA(1)(b).

approved billing agent means a person or body in respect of whom an approval under section 20AB is in force.

approved form means a form approved by the Minister, by writing signed by him or her, for the purposes of the provision in which the expression occurs.

approved pathology authority means a person in respect of whom there is in force an undertaking given by the person, and accepted by the Minister, under section 23DF.

approved pathology practitioner means a person in respect of whom there is in force an undertaking given by the person, and accepted by the Minister, under section 23DC.

associate, of a person in relation to a professional service: see subsection 19AD(4).

Australia includes Norfolk Island, the Territory of Cocos (Keeling) Islands and the Territory of Christmas Island.

Australian resident means a person who resides in Australia and who is:

(a) an Australian citizen; or
(b) a person who is, within the meaning of the Migration Act 1958, the holder of a permanent visa; or
(ba) a person who has been granted, or who is included in, a return endorsement or a resident return visa in force under the Migration Act 1958; or
(c) a New Zealand citizen who is lawfully present in Australia; or
(d) a person (not being a person referred to in paragraph (a), (b), (ba) or (c)) who is lawfully present in Australia and whose continued presence in Australia is not subject to any limitation as to time imposed by law; or
(f) a person who:
(i) is, within the meaning of the Migration Act 1958, the holder of a temporary visa; and
(ia) is not covered by regulations made under subsection 6A(1); and
(ii) has applied for a permanent visa under that Act and the application has not been withdrawn or otherwise finally determined; and
(iii) has not, both:
(A) on or after the commencement of this paragraph, made an application for a protection visa under that Act (whether or not the person has applied for any other visa), other than an application that has been withdrawn or otherwise finally determined; and
(B) whether before or after the commencement of this paragraph, made an application for a parent visa under that Act (whether or not the person has applied for any other visa and whether or not the application for the parent visa has been withdrawn or otherwise finally determined); and
(iv) has not, whether before or after the commencement of this paragraph, made an application for a parent visa under that Act (whether or not the person has applied for any other visa), other than an application that has been withdrawn or otherwise finally determined; and
(v) in respect of whom either:
(A) another person, being the person’s spouse, parent or child (each having the same meaning as in the Migration Act 1958), is an Australian citizen or the holder of a permanent visa under that Act; or
(B) an authority to work in Australia is in force.

Australian university has the same meaning as in the Higher Education Support Act 2003.

authorised representative has the same meaning as in the My Health Records Act 2012.

bank includes, but is not limited to, a body corporate that is an ADI (authorised deposit‑taking institution) for the purposes of the Banking Act 1959.

base for mobile diagnostic imaging equipment has the meaning given by section 23DZL.

base for mobile radiation oncology equipment has the meaning given by section 23DZZK.

Bonded Medical Program: see section 124ZD.

Bonded Medical Program rules: see section 124ZT.

bonded participant: see section 124ZE.

census date has the same meaning as in the Higher Education Funding Act 1988.

Chief Executive Centrelink has the same meaning as in the Human Services (Centrelink) Act 1997.

Chief Executive Medicare has the same meaning as in the Human Services (Medicare) Act 1973.

chiropractor means a person who is registered under the National Law in the chiropractic profession.

civil penalty order means an order under subsection 125A(2).

civil penalty provision has the meaning given by section 125B.

clinically relevant service means a service rendered by a medical or dental practitioner or an optometrist that is generally accepted in the medical, dental or optometrical profession (as the case may be) as being necessary for the appropriate treatment of the patient to whom it is rendered.

complying health insurance policy has the meaning given by section 63‑10 of the Private Health Insurance Act 2007.

consultant physician, in relation to a particular specialty (other than general practice), means a medical practitioner in relation to whom there is in force a determination under section 3DB or 3E that the medical practitioner is recognised for the purposes of this Act as a consultant physician in that specialty.

course of study in medicine has the same meaning as in the Higher Education Support Act 2003.

dental benefit has the same meaning as in the Dental Benefits Act 2008.

dental practitioner means a person who is registered under the National Law in the dental profession.

diagnostic imaging accreditation scheme means a scheme established by the Minister under section 23DZZIAA.

diagnostic imaging equipment means equipment that is primarily used in the carrying out of a diagnostic imaging procedure.

diagnostic imaging premises has the meaning given by section 23DZM.

diagnostic imaging procedure means a procedure for the production of images (for example, X‑rays, computerised tomography scans, ultrasound scans, magnetic resonance imaging scans and nuclear scans) for use in the rendering of diagnostic imaging services.

Diagnostic Imaging Register means the Register kept under section 23DZK.

diagnostic imaging service means:

(a) an R‑type diagnostic imaging service; or
(b) an NR‑type diagnostic imaging service;

to which an item of the diagnostic imaging services table relates.

diagnostic imaging services table means the table prescribed under section 4AA.

disclose, in relation to information, includes divulge or communicate.

eligible location means:

(a) an area prescribed by the Bonded Medical Program rules as a regional, rural or remote area; or
(b) an area prescribed by the Bonded Medical Program rules as an area of workforce shortage.

eligible midwife has the meaning given by section 21.

eligible nurse practitioner means a person who:

(a) is a nurse practitioner; and
(b) meets the requirements (if any) specified in the regulations for the purposes of this paragraph.

eligible overseas representative means a person who is:

(a) the head of a diplomatic mission of another country, or the head of a consular post of another country, established in Australia; or
(b) a member of the staff of such a diplomatic mission, or a member of the staff of such a consular post; or
(c) a member of the family of a person referred to in paragraph (a) or (b), being a member who forms part of the household of that person;

being a person who is neither an Australian citizen nor a person domiciled in Australia but who, under an agreement between the Government of the Commonwealth and the Government of that other country, is to be treated, for the purpose of the provision of medical, hospital and other care, as if the person were an Australian resident.

eligible person means an Australian resident or an eligible overseas representative.

entrusted public official means any of the following:

(a) the Minister;
(b) the Chief Executive Medicare;
(c) the Secretary of a relevant Department;
(d) an APS employee in a relevant Department;
(e) a Departmental employee within the meaning of the Human Services (Medicare) Act 1973;
(f) any other person employed or engaged by the Commonwealth to provide services to the Commonwealth in connection with a relevant Department or Services Australia;
(g) any other person employed or engaged (however described) by a person described in paragraph (f) to provide services in connection with the services mentioned in that paragraph.

excessive pathology service means a pathology service:

(a) in respect of which medicare benefit has become or may become payable; and
(b) that is not reasonably necessary for the adequate medical or dental care of the patient concerned.

extended compliance determination has the meaning given by subsection 124ZUA(1).

finally determined has the same meaning as in the Migration Act 1958.

friendly society means:

(a) a body that is a friendly society for the purposes of the Life Insurance Act 1995; or
(b) a body that is registered or incorporated as a friendly society under a law of a State or Territory; or
(c) a body that is permitted, by a law of a State or Territory, to assume or use the expression friendly society; or
(d) a body that, immediately before the date that is the transfer date for the purposes of the Financial Sector Reform (Amendments and Transitional Provisions) Act (No. 1) 1999, was registered or incorporated as a friendly society under a law of a State or Territory.

general medical services table, means the table prescribed under section 4.

general practitioner means:

(a) a medical practitioner who is registered under the National Law in the specialty of general practice; or
(b) a medical practitioner of a kind prescribed by the regulations for the purposes of this paragraph.

guidance and appeals panel has the same meaning as in the Administrative Review Tribunal Act 2024.

guidance and appeals panel application has the same meaning as in the Administrative Review Tribunal Act 2024.

hospital has the meaning given by subsection 121‑5(5) of the Private Health Insurance Act 2007.

hospital service means a health service of a kind provided in a hospital and includes:

(a) accommodation in a hospital for the purposes of receiving treatment; and
(b) nursing care and treatment; and
(c) medical care and treatment including diagnostic services; and
(d) outpatient, accident and emergency services.

hospital‑substitute treatment has the same meaning as in the Private Health Insurance Act 2007.

hospital treatment has the meaning given by section 121‑5 of the Private Health Insurance Act 2007.

Human Services Minister means the Minister administering the Human Services (Centrelink) Act 1997.

Immigration Department means the Department administered by the Minister administering the Migration Act 1958.

initiate, in relation to a pathology service or a diagnostic imaging service, means make the decision by reason of which the service is rendered.

item means an item in the table.

listed:

(a) in relation to diagnostic imaging equipment—has the meaning given by subsections 16D(4) and (5); and
(b) in relation to radiation oncology equipment—has the meaning given by subsections 16F(6) and (7).

medical entrepreneur has the meaning given by section 3B.

medical expenses means an amount payable in respect of a professional service.

medical practitioner means a person who is registered under the National Law in the medical profession.

medicare benefit means a medicare benefit under Part II.

medicare number has the same meaning as in subsection 84(1) of the National Health Act 1953.

medicare program has the same meaning as in the Human Services (Medicare) Act 1973.

midwife means a person who is registered under the National Law in the midwifery profession.

Migration Regulations means regulations made under the Migration Act 1958.

month means a month of the year.

My Health Record system has the same meaning as in the My Health Records Act 2012.

My Health Record System Operator means the System Operator within the meaning of the My Health Records Act 2012.

National Law means:

(a) for a State or Territory (other than Western Australia)—the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld), as it applies (with or without modification) as a law of the State or Territory; or
(b) for Western Australia—the Health Practitioner Regulation National Law (WA) Act 2010 (WA), so far as that Act corresponds to the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld).

nominated representative has the same meaning as in the My Health Records Act 2012.

NR‑type diagnostic imaging service means a diagnostic imaging service corresponding to an item of the diagnostic imaging services table that is classified as an NR‑type service in the table.

nurse practitioner means a person who is registered under the National Law in the nursing profession as a nurse practitioner.

nursing care means nursing care given by or under the supervision of a registered nurse.

nursing‑home type patient, in relation to a hospital, means a patient in the hospital who has been provided with accommodation and nursing care, as an end in itself, for a continuous period exceeding 35 days.

optometrist means a person who is registered under the National Law in the optometry profession.

ordinarily located:

(a) in relation to diagnostic imaging premises—has a meaning affected by subsection 16D(6); and
(b) in relation to bases for mobile diagnostic imaging equipment—has a meaning affected by subsection 16D(8); and
(c) in relation to radiation oncology premises—has a meaning affected by subsection 16F(8); and
(d) in relation to bases for mobile radiation oncology equipment—has a meaning affected by subsection 16F(10).

organization means a society, body or group of persons, whether corporate or unincorporate.

osteopath means a person who is registered under the National Law in the osteopathy profession.

out‑patient service, in relation to a hospital, means a health service or procedure provided by the hospital to an eligible person other than a patient of the hospital.

paid work means work for financial gain or reward (whether as an employee, a self‑employed person or otherwise).

parent visa: a person has applied for a parent visa if:

(a) the person has applied for a permanent visa included in a class of visas under the Migration Regulations, being a class that has the word “parent” in its title; or
(b) before 1 November 1999 the person applied for a Change in Circumstance (Residence) (Class AG) visa, a Family (Residence) (Class AO) visa or a General (Residence) (Class AS) visa under the Migration Regulations and:
(i) the person was nominated for the grant of that visa by a child of the person, being a child who was at least 18 years old when the application was made; or
(ii) the person was included in an application made by a person covered by subparagraph (i).

participating midwife means:

(a) if the Minister has approved a common form of undertaking under section 21A—an eligible midwife in respect of whom there is in force an undertaking given by him or her and accepted by the Minister under section 21B; or
(b) otherwise—an eligible midwife.

participating nurse practitioner means:

(a) if the Minister has approved a common form of undertaking under section 22—an eligible nurse practitioner in respect of whom there is in force an undertaking given by him or her and accepted by the Minister under section 22A; or
(b) otherwise—an eligible nurse practitioner.

pathologist‑determinable service means a pathology service specified, or a pathology service included in a class of pathology services specified, in a determination in force under section 4BA.

pathology service means a medical service to which an item of the pathology services table relates.

pathology services table, means the table prescribed under section 4A.

patient, in relation to a hospital, does not include:

(a) a member of the staff of the hospital who is receiving treatment in his or her own quarters; or
(b) except as provided by subsection (2), a newly‑born child whose mother also occupies a bed in the hospital.

patient contribution means:

(b) in relation to a nursing‑home type patient of a recognized hospital in a State such amount as is determined by the Minister from time to time for the purposes of this paragraph with respect to that State;
(c) in relation to a nursing‑home type patient of a recognized hospital in an internal Territory, such amount as is determined by the Minister from time to time for the purposes of this paragraph in relation to that Territory; or
(d) in relation to a nursing‑home type patient of a private hospital in a State or internal Territory, such amount as is determined by the Minister from time to time for the purposes of this paragraph with respect to that State or Territory.

pecuniary penalty order means an order made under section 125A.

permanent visa has the same meaning as in the Migration Act 1958.

physiotherapist means a person who is registered under the National Law in the physiotherapy profession.

podiatrist means a person who is registered under the National Law in the podiatry profession.

practitioner means a medical practitioner or a dental practitioner.

prescribed pathology service means a pathology service specified, or a pathology service included in a class of pathology services specified, in a determination in force under section 4BB.

primary information:

(a) for the purposes of Division 4 of Part IIB—has the meaning given by section 23DZR; and
(b) for the purposes of Part IIC—has the meaning given by section 23DZZQ.

private health insurer has the same meaning as in the Private Health Insurance Act 2007.

private hospital means a hospital in respect of which there is in force a statement under subsection 121‑5(8) of the Private Health Insurance Act 2007 that the hospital is a private hospital.

private patient, in relation to a hospital, means a patient of the hospital who is not a public patient.

professional attention means:

(a) medical or surgical treatment by or under the supervision of a medical practitioner; or
(b) obstetric treatment by or under the supervision of a medical practitioner or a registered nurse with obstetric qualifications; or
(c) dental treatment by or under the supervision of a dental practitioner; or
(d) podiatric treatment by an accredited podiatrist.

professional service means:

(a) a service (other than a diagnostic imaging service) to which an item relates, being a clinically relevant service that is rendered by or on behalf of a medical practitioner; or
(b) a prescribed medical service to which an item relates, being a clinically relevant service that is rendered by a dental practitioner approved by the Minister in writing for the purposes of this definition; or
(c) a service to which an item relates, being a clinically relevant service that is rendered by an optometrist; or
(d) a pathology service that is rendered by or on behalf of an approved pathology practitioner pursuant to a request made in accordance with subsection 16A(4) by:
(i) a treating practitioner; or
(ii) another approved pathology practitioner who received a request for the service made by the treating practitioner; or
(e) a pathology service (other than a service referred to in paragraph (d)) that is a clinically relevant service rendered by or on behalf of an approved pathology practitioner other than a medical practitioner; or
(f) a diagnostic imaging service that is rendered by or on behalf of a medical practitioner pursuant to a subsection 16B(1) request; or
(g) a diagnostic imaging service (other than a service referred to in paragraph (f)) that is a clinically relevant service rendered by or on behalf of a medical practitioner.

Note: See subsection (17) for when a service is taken to be rendered on behalf of a medical practitioner.

proprietor:

(a) in relation to a pathology laboratory—means the person or authority having effective control of:
(i) the laboratory premises, whether or not the holder of an estate or interest in the premises; and
(ii) the use of equipment used in the laboratory; and
(iii) the employment of staff in the laboratory; and
(b) in relation to diagnostic imaging premises or a base for mobile diagnostic imaging equipment—has the meaning given by section 23DZO; and
(c) in relation to radiation oncology premises or a base for mobile radiation oncology equipment—has the meaning given by section 23DZZN; and
(d) in relation to other premises—means the person, authority or body of persons having effective control of the premises, whether or not he or she or it is the holder of an estate or interest in the premises.

protection visa means a permanent or temporary visa included in a class of visas under the Migration Regulations, being a class that has the word “protection” in its title.

public hospital service means a hospital service provided in:

(a) a recognised hospital; or
(b) a hospital in respect of which the Commonwealth, or a State, provides funding for the provision of hospital services to public patients.

public patient, in relation to a hospital, means a patient in respect of whom the hospital provides comprehensive care, including all necessary medical, nursing and diagnostic services and, if they are available at the hospital, dental and paramedical services, by means of its own staff or by other agreed arrangements.

radiation oncology equipment means equipment that is primarily used in rendering a radiation oncology service.

radiation oncology premises has the meaning given by section 23DZZL.

Radiation Oncology Register means the Register kept under section 23DZZJ.

radiation oncology service has the meaning given by subsection 16F(2).

recognised hospital means a hospital in respect of which there is in force a statement under subsection 121‑5(8) of the Private Health Insurance Act 2007 that the hospital is a public hospital.

registered:

(a) in relation to diagnostic imaging premises—has the meaning given by subsection 16D(2); and
(b) in relation to a base for mobile diagnostic imaging equipment—has the meaning given by subsection 16D(3); and
(c) in relation to radiation oncology premises—has the meaning given by subsection 16F(4); and
(d) in relation to a base for mobile radiation oncology equipment—has the meaning given by subsection 16F(5).

registered nurse means a person who is registered under the National Law in the nursing profession as a registered nurse.

relevant dental benefits offence means:

(a) an offence against section 50, 51, 52, 53 or 54 of the Dental Benefits Act 2008; or
(b) an offence against:
(i) section 6 of the Crimes Act 1914; or
(ii) section 11.1, 11.4 or 11.5 of the Criminal Code;
that relates to an offence referred to in paragraph (a) of this definition; or
(c) an offence against section 134.1, 134.2, 135.1, 135.2, 135.4, 136.1, 137.1, 144.1, 145.1, 145.4 or 145.5 of the Criminal Code that relates to a claim for payment in respect of the rendering of a dental service (within the meaning of the Dental Benefits Act 2008).

relevant Department means any of the following:

(a) the Department administered by the Minister who administers this Act;
(b) the Department administered by the Minister who administers the Dental Benefits Act 2008;
(c) the Department administered by the Minister who administers the Human Services (Centrelink) Act 1997;
(d) the Department administered by the Minister who administers the Human Services (Medicare) Act 1973;
(e) the Department administered by the Minister who administers the National Health Act 1953.

resolved, in relation to an application under section 19AE: see subsections 19AE(10) and (11).

return of service obligation: see section 124ZF.

RoSO compliance period means the period referred to in paragraph 124ZF(2)(a).

R‑type diagnostic imaging service means a diagnostic imaging service corresponding to an item of the diagnostic imaging services table that is classified as an R‑type service in the table.

Rural Health Minister means the Minister responsible for health in rural, regional or remote areas.

Secretary means the Secretary of the Department.

shares with the My Health Record system has the same meaning as in the My Health Records Act 2012.

specialist, in relation to a particular specialty (other than general practice), means a medical practitioner in relation to whom there is in force a determination under section 3DB or 3E that the medical practitioner is recognised for the purposes of this Act as a specialist in that specialty, or a medical practitioner who is taken to be so recognised under section 3D.

subsection 16B(1) request means a request of a kind referred to in subsection 16B(1).

table means the table consisting of:

(a) the general medical services table; and
(b) the pathology services table; and
(c) the diagnostic imaging services table.

upload exception applies: see subsection 19AD(3).

upload rules: see section 19AI.

use, in relation to information, includes make a record of.

Veterans’ Affairs Department means the Department administered by the Veterans’ Affairs Minister.

Veterans’ Affairs Minister means the Minister administering the Veterans’ Entitlements Act 1986.

(1A) In this Act, unless the contrary intention appears, a word or phrase defined for the purposes of the National Health Act 1953 has the meaning that it would have if used in that Act. (2) For the purposes of this Act: (a) a newly‑born child who occupies an approved bed in an intensive care facility in a hospital, being a facility approved by the Minister for the purposes of this subsection, for the purpose of the provision of special care shall be deemed to be a patient of the hospital; and (b) where there are two or more newly born children of the same mother in a hospital and those children are not in‑patients of the hospital by virtue of paragraph (a)—each such child in excess of 1 shall be deemed to be a patient of the hospital. (3) Where an anaesthetic is administered to a patient: (a) pre‑medication of the patient in preparation for the administration of the anaesthetic; and (b) pre‑operative examination of the patient in preparation for the administration of the anaesthetic, being an examination carried out during the attendance at which the anaesthetic is administered; shall, for the purposes of this Act, be deemed to form part of the professional service constituted by the administration of the anaesthetic. (4) Unless the contrary intention appears, a reference in this Act to a professional attendance or to an attendance is a reference to an attendance by a medical practitioner on a patient, including an attendance at the medical practitioner’s rooms or surgery. (5) Unless the Minister otherwise directs, a professional service, not being a service specified in an item in the general medical services table that is expressed to relate to a professional attendance by a medical practitioner (however described), a dental practitioner, an optometrist, a participating midwife or a participating nurse practitioner, shall be deemed to include all professional attendances necessary for the purposes of post‑operative treatment of the person to whom the professional service is rendered. (5A) For the purposes of this Act, a pathology service shall be deemed to include any necessary interpretation, analysis or reporting. (5B) For the purposes of this Act, a diagnostic imaging service is taken to include any necessary interpretation, analysis or reporting. (5C) For the purposes of this Act, if the descriptions of 2 diagnostic imaging services in the diagnostic imaging services table differ from each other only so far as one service is indicated to be an R‑type diagnostic imaging service and the other is indicated to be an NR‑type diagnostic imaging service, the first‑mentioned service is taken to be an R‑type diagnostic imaging service for which there is a corresponding NR‑type diagnostic imaging service. (6) Where a professional service rendered to a person includes a medical procedure that would, but for this subsection, itself be a professional service, that procedure shall, in respect of that person, be deemed not to be a professional service. (14) For the purposes of the definition of patient contribution in subsection (1), Norfolk Island is taken to form part of the State of New South Wales. (15) For the purposes of the definition of recognized hospital in subsection (1), State includes the Northern Territory. (16) In approving a form for the purposes of the definition of approved form in subsection (1), the Minister may specify a disc, tape, film or other medium as the means by which the information to be contained in the form is to be or may be set out. (17) For the purposes of this Act and the regulations, a service is taken to be rendered on behalf of a medical practitioner if, and only if: (a) it is rendered by another person who is not a medical practitioner, and who provides the service, in accordance with accepted medical practice, under the supervision of the medical practitioner; and (b) it is not a service of a kind specified in regulations made for the purposes of this paragraph. (18) If: (a) a professional service prescribed by the regulations for the purposes of this paragraph is rendered by a medical practitioner who is a specialist trainee (see subsection (20)); and (b) the specialist trainee renders the service under the supervision of another medical practitioner who is present at all times while the specialist trainee renders the service; then, for the purposes of this Act and the regulations: (c) the service is taken to have been rendered by the other medical practitioner; and (d) the service is taken not to have been rendered by the specialist trainee. (19) The regulations may prescribe provisions of this Act and of the regulations to which subsection (18) does not apply. (20) In subsection (18):

specialist trainee has the meaning given by regulations made for the purposes of this subsection.

3AAA

Accreditation of podiatrists

3AAA Accreditation of podiatrists

(1) The Minister may, in accordance with guidelines determined under subsection (2), decide whether to accredit a podiatrist. (2) The Minister may, by legislative instrument: (a) determine guidelines for making a decision as to whether a podiatrist is to be accredited; and (b) from time to time, vary or revoke any guidelines so made. (3) A decision as to whether a podiatrist should be accredited must be made in accordance with the guidelines in force at the time the decision is made. (5) As soon as practicable after making a decision to accredit, or to refuse to accredit, a podiatrist, the Minister must notify the podiatrist, in writing, of that decision. If the decision is a decision to refuse to accredit, the notification must include reasons for the refusal.

3AAB

Review by Administrative Review Tribunal

3AAB Review by Administrative Review Tribunal

If the Minister has made a decision refusing to accredit a podiatrist, application may be made to the Administrative Review Tribunal for review of the decision.

3AA

Approved pathology practitioners to ensure proper supervision of pathology services

3AA Approved pathology practitioners to ensure proper supervision of pathology services

(1) For the purposes of this Act, a pathology service is not taken to be rendered on behalf of an approved pathology practitioner unless the practitioner has arranged for proper supervision of the rendering of the service. (2) For the purposes of this Act, an approved pathology practitioner is not taken to have arranged for proper supervision of the rendering of a pathology service unless the practitioner: (a) ensures that a properly qualified person supervises the rendering of the service; and (b) has personal responsibility for the proper rendering of the service. (3) The question whether an approved pathology practitioner ensured that a properly qualified person supervised the rendering of a pathology service is to be determined in accordance with principles determined under subsection (4) by the Minister. (4) The Minister may, by legislative instrument, determine principles for the purposes of subsection (3).

Meaning of medical entrepreneur

3B Meaning of medical entrepreneur

For the purposes of this Act, a person is a medical entrepreneur if the person: (a) employs a person mentioned in an item in the following table to render a service mentioned in the item; or (b) is in a position to exercise control over a person mentioned in an item in the table rendering a service mentioned in the item; or (c) leases, or otherwise makes available, to another person mentioned in an item in the table premises at which the other person renders a service mentioned in the item; or (d) receives or obtains any property, benefit or advantage from the rendering of a service mentioned in an item in the table by a person mentioned in the item.

Item	Column 1Person	Column 2Service
1	practitioner	medical service
2	participating midwife	midwifery service
3	participating nurse practitioner	nurse practitioner service

Health service not specified in an item

3C Health service not specified in an item

(1) The Minister may, by legislative instrument, determine that: (a) a specified health service, or a health service included in a specified class of health services, being a health service not specified in an item in the table, shall, or shall in specified circumstances, be treated, for the purposes of specified provisions of this Act, the regulations, the National Health Act 1953 or the regulations under that Act, as if: (i) the health service were whichever of the following is specified in the determination, namely: (A) both a professional service and a medical service; (B) a medical service; and (ii) there were an item in the general medical services table, the pathology services table or the diagnostic imaging services table that: (A) related to the health service; and (B) specified in respect of the health service a fee in relation to a State, being the fee and the State specified in the determination in relation to the health service; and (b) a specified provision of the regulations, a specified instrument made under or given pursuant to this Act or a specified provision of a specified instrument made under or given pursuant to this Act, being a provision or instrument, as the case may be, in which all or any of the following are specified, namely, a professional service, medical service or item, shall, or shall in specified circumstances, have effect as if: (i) the health service; or (ii) the item that, by virtue of subparagraph (a)(ii), relates to the health service; as the case requires, were also specified in the provision or instrument, as the case may be. (2) Subsection 12(2) of the Legislation Act 2003 does not apply to a determination under subsection (1) of this section.

Note: Subsection 12(2) of the Legislation Act 2003 is about the retrospective application of legislative instruments.

(2A) A determination under subsection (1) may provide that the total of all amounts of medicare benefit paid or payable in respect of one or more eligible dental services provided to a person in a specified period must not exceed a specified amount. (2B) If a determination makes provision as mentioned in subsection (2A), medicare benefit is not payable, despite Part II, in respect of an eligible dental service provided to a person in the specified period to the extent that the total of all amounts of medicare benefit paid or payable for all such eligible dental services provided to the person in the specified period exceeds the specified amount. (3) A determination made under subsection (1) may make provision for and in relation to the specification of a matter or thing by applying, adopting or incorporating, with or without modification, the provisions of this Act or the regulations as in force at a particular time or as in force from time to time. (7) For the purposes of this section, an internal Territory shall be deemed to form part of the State of New South Wales. (7A) For the purposes of this section, Norfolk Island is taken to form part of the State of New South Wales. (8) In this section:

eligible dental service means:

(a) dental treatment; and
(b) a health service described in paragraph (d) of the definition of health service.

health service means:

(a) medical, surgical, obstetric, dental or optometrical treatment; and
(b) any other prescribed service, or service included in a prescribed class of services, whether or not related to treatment referred to in paragraph (a), that relates to health; and
(d) the supply of prostheses in connection with dental treatment;

but does not include the supply of any other prostheses.

service includes the supply of goods.

Recognition as specialists of members of certain organisations on advice from the organisation

3D Recognition as specialists of members of certain organisations on advice from the organisation

(1) A medical practitioner is taken to be recognised as a specialist in a particular specialty (other than general practice), for the purposes of this Act, if a relevant organisation in relation to the specialty gives the Chief Executive Medicare written notice stating that the medical practitioner meets the criteria for the specialty (see subsection (2)). (2) A medical practitioner meets the criteria for a specialty if the medical practitioner: (a) is domiciled in Australia; and (b) is a fellow of a relevant organisation in relation to the specialty (other than general practice); and (c) has obtained, as a result of successfully completing an appropriate course of study, a relevant qualification in relation to the relevant organisation. (3) The Chief Executive Medicare must notify the medical practitioner as soon as reasonably practicable of his or her recognition as a specialist in the specialty (other than general practice). (4) This section does not limit section 3DB. (5) In this section:

relevant organisation, in relation to a specialty (other than general practice), means an organisation declared by the regulations to be a professional organisation in relation to the specialty.

relevant qualification, in relation to a relevant organisation, means a qualification declared by the regulations to be a relevant qualification in relation to the relevant organisation.

3DA

Period of section 3D recognition

3DA Period of section 3D recognition

(1) The recognition of a medical practitioner as a specialist in a particular specialty (other than general practice) under subsection 3D(1) has effect, or is taken to have had effect, on and from the day specified in the notice given to the medical practitioner under subsection 3D(3). (2) The day specified may be before the day on which the notice is given, but must not be before the day specified by the relevant organisation to be the day on which the medical practitioner first met the criteria for the specialty. (3) The recognition of a medical practitioner as a specialist in a specialty (other than general practice) under subsection 3D(1) ceases if: (a) a relevant organisation in relation to the specialty gives the Chief Executive Medicare written notice stating that the medical practitioner no longer meets the criteria for the specialty, or has ceased to practise medicine in Australia; or (b) the medical practitioner requests that he or she cease to be so recognised.

Note: A medical practitioner’s recognition as a specialist cannot cease under this subsection if that recognition is due to Schedule 3 to the Health and Ageing Legislation Amendment Act 2004.

3DB

Alternative method of recognition as a specialist or consultant physician

3DB Alternative method of recognition as a specialist or consultant physician

(1) A medical practitioner may apply to the Minister for a determination that the medical practitioner is a specialist or consultant physician in a particular specialty (other than general practice) if: (a) the medical practitioner is domiciled in Australia; and (b) the medical practitioner is registered under the National Law as a specialist in a particular specialty (other than general practice). (2) A medical practitioner may also apply to the Minister for a determination that the medical practitioner is a specialist or consultant physician in a particular specialty (other than general practice) if the medical practitioner meets the criteria for the specialty, within the meaning of subsection 3D(2). (3) An application under subsection (1) or (2) must be in writing. (4) After receiving an application under subsection (1) or (2), the Minister must: (a) determine that the medical practitioner be recognised, for the purposes of this Act, as a specialist or consultant physician (as the case requires) in the specialty; and (b) notify the medical practitioner, in writing, of his or her recognition as a specialist or consultant physician in the specialty. (5) A notification under paragraph (4)(b) is not a legislative instrument.

3DC

Period of effect of determination

3DC Period of effect of determination

(1) A determination under paragraph 3DB(4)(a) that a medical practitioner is recognised as a specialist or consultant physician in a particular specialty (other than general practice) has effect, or is taken to have had effect, on and from the day specified in the determination. (2) The day specified may be before the day on which the determination is made. (3) The determination ceases to have effect if: (a) the medical practitioner ceases to be domiciled in Australia; or (b) the medical practitioner ceases to practise medicine in Australia. (4) The Minister must revoke the determination if the medical practitioner requests that the Minister do so.

Recognition as consultant physicians etc. of certain medical practitioners

3E Recognition as consultant physicians etc. of certain medical practitioners

(1) The Minister may make a determination in writing that a particular medical practitioner who is not domiciled in Australia should be recognised for the purposes of this Act for a specified period as a consultant physician, or as a specialist, in a particular specialty (other than general practice). (2) The Minister shall not make a determination under subsection (1) in relation to a medical practitioner except on application by the practitioner. (2A) A determination under subsection (1) has effect, or is taken to have had effect: (a) on and from the day specified for the purpose by the Minister in the determination; or (b) if no such day is specified—on and from the day on which the determination is made. (2B) A day specified under paragraph (2A)(a) may be a day that occurred before the day on which the determination is made. (3) The Minister may at any time revoke a determination made in relation to a medical practitioner under subsection (1) by giving a notice in writing to that effect to the medical practitioner.

3GA

Register of Approved Placements

3GA Register of Approved Placements

(1) The purpose of this section is to provide for registration of certain medical practitioners in approved placements. (2) The Chief Executive Medicare is to establish and maintain a Register of Approved Placements. (3) The Register may be maintained in any form, including as a computer record. (4) A medical practitioner may apply to the Chief Executive Medicare for registration under this section. (5) If a medical practitioner makes an application and: (a) a body specified in the regulations gives the Chief Executive Medicare written notice stating: (i) that the applicant is enrolled in, or undertaking, a course or program of a kind specified in the regulations; and (ii) the period over which, and the location in which, the applicant will be undertaking the course or program; or (b) the applicant is, in accordance with the regulations, eligible for registration under this section; the Chief Executive Medicare must, within the required period under subsection (6), enter the applicant’s name in the Register, together with the period in respect of which and the location in respect of which the applicant is registered. (6) The required period for the purposes of subsection (5) is: (a) if a notice was given to the Chief Executive Medicare under paragraph (5)(a) in connection with the application: (i) the period of 14 days after the notice was received by the Chief Executive Medicare; or (ii) if the application was made after the notice was received—the period of 14 days after the application was received by the Chief Executive Medicare; or (b) if no such notice was given—the period of 14 days after the application was received by the Chief Executive Medicare. (7) The Chief Executive Medicare must give the applicant written notice of the day on which the applicant’s name is to be entered in the Register. (8) The Chief Executive Medicare may give a body specified in regulations made for the purposes of paragraph (5)(a) information about the following matters, to the extent that those matters relate to persons about whom the body has given a notice under paragraph (5)(a): (a) the current state of the Register; (b) additions to the Register; (c) deletions from the Register.

3GB

Removal from the Register

3GB Removal from the Register

(1) The Chief Executive Medicare must remove a medical practitioner’s name from the Register of Approved Placements if: (a) the medical practitioner requests the Chief Executive Medicare to do so; or (b) a body specified in regulations made for the purposes of paragraph 3GA(5)(a) gives the Chief Executive Medicare written notice that the medical practitioner (being a person about whom the body gave a notice under paragraph (5)(a)) is not enrolled in, or undertaking, the course or program in relation to which he or she was registered; or (c) the regulations require that the medical practitioner’s name be removed from the Register. (2) Before removing the medical practitioner’s name from the Register, the Chief Executive Medicare must give the medical practitioner written notice that his or her name is to be removed. (3) The notice must specify the day on which the medical practitioner’s name is to be removed from the Register. (4) The day specified under subsection (3) must not be less than 14 days after the day on which the notice is given.

3GC

Use of computer programs to manage Register of Approved Placements

3GC Use of computer programs to manage Register of Approved Placements

(1) The Chief Executive Medicare may arrange for the use, under the Chief Executive Medicare’s control, of computer programs for taking actions required by section 3GA or 3GB. (2) An action taken by the operation of a computer program under such an arrangement is taken to be an action by the Chief Executive Medicare. (3) The Chief Executive Medicare may substitute an action for an action the Chief Executive Medicare is taken to have made under subsection (2) if the Chief Executive Medicare is satisfied that the action taken by the operation of the computer program is incorrect.

General medical services table

4 General medical services table

(1) The regulations may prescribe a table of medical services (other than diagnostic imaging services and pathology services) that sets out the following: (a) items of medical services; (b) the amount of fees applicable in respect of each item; (c) rules for interpretation of the table.

Note: See also section 4BAA (conditional specification of services in table items).

(3) If: (a) a person renders a professional service; and (b) a claim is made for an amount to be paid under this Act in respect of the service; and (c) the service is specified in an item in the general medical services table; and (d) the item mentions the creation (however described) of a document; and (e) the document is created by the person; the person must retain the document for the period of 2 years beginning on the day the service is rendered.

Civil penalty: 5 penalty units.

(4) Subsection (3) does not apply if the person has a reasonable excuse.

Note: A person who wishes to rely on subsection (4) in proceedings for a civil penalty order bears an evidential burden in relation to the matter in that subsection (see section 130H).

4AAA

Multiple general medical services

4AAA Multiple general medical services

(1) This section does not limit the generality of section 4. (2) A regulation under section 4 may provide for a reduction in the fee applicable to a medical service (other than a diagnostic imaging service or a pathology service), where: (a) that service; and (b) at least one other service, which may be a diagnostic imaging service or a pathology service; are provided to the same patient.

4AA

Diagnostic imaging services table

4AA Diagnostic imaging services table

The regulations may prescribe a table of diagnostic imaging services that sets out the following: (a) items of R‑type diagnostic imaging services; (b) items of NR‑type diagnostic imaging services; (c) the amount of fees applicable in respect of each item; (d) rules for interpretation of the table.

Note: See also section 4BAA (conditional specification of services in table items).

4AB

Multiple diagnostic imaging services

4AB Multiple diagnostic imaging services

(1) This section does not limit the generality of section 4AA. (2) A regulation under section 4AA may provide for a reduction in the fee applicable to a diagnostic imaging service, where: (a) that service; and (b) at least one other medical service, which may be a service other than a diagnostic imaging service; are provided to the same patient.

Pathology services table

4A Pathology services table

The regulations may prescribe a table of pathology services that sets out the following: (a) items of pathology services; (b) the amount of fees applicable in respect of each item; (c) rules for interpretation of the table.

Note: See also section 4BAA (conditional specification of services in table items).

Multiple pathology services

4B Multiple pathology services

(1) This section has effect without limiting the generality of section 4A. (2) A regulation under section 4A may make provision, by way of a rule of interpretation, for two or more pathology services to be treated, in specified circumstances, as one pathology service. (3) Where, in accordance with the pathology services table, two or more pathology services are to be treated as one pathology service, the Minister may, if he or she is satisfied in a particular case that the circumstances justify his or her so doing, direct that any of the services that, but for this subsection, would be treated as one service shall not be so treated.

4BAA

Conditional specification of services in table items

4BAA Conditional specification of services in table items

(1) The specification of a service in an item in a table prescribed under section 4, 4AA or 4A may be: (a) unconditional; or (b) subject to such conditions, limitations or restrictions as are specified in: (i) the item; or (ii) the rules for interpretation of the table. (2) If there is such a condition, limitation or restriction, a service will be regarded as a service specified in the item, or as a service to which the item relates, only if the service falls within the condition, limitation or restriction. (3) This section applies to a table prescribed before or after the commencement of this section. (4) This section is enacted for the avoidance of doubt.

4BA

Pathologist‑determinable services

4BA Pathologist‑determinable services

The Minister may, after consulting the Royal College of Pathologists of Australasia, determine, by legislative instrument, that: (a) a pathology service specified in the determination is a pathologist‑determinable service for the purposes of this Act; or (b) pathology services included in a class of pathology services specified in the determination are pathologist‑determinable services for the purposes of this Act.

4BB

Prescribed pathology services

4BB Prescribed pathology services

The Minister may determine, by legislative instrument, that: (a) a pathology service specified in the determination is a prescribed pathology service for the purposes of this Act; or (b) pathology services included in a class of pathology services specified in the determination are prescribed pathology services for the purposes of this Act.

Certain persons in Australia to be treated as eligible persons etc.

6 Certain persons in Australia to be treated as eligible persons etc.

(1) The Minister may, by order in writing, declare that a specified person, or every person included in a specified class of persons, being a person who, but for this subsection, would not be an eligible person for the purposes of this Act, shall, or shall in specified circumstances (whether circumstances that occurred before or occur after the making of the order) in which he or she was or is in Australia, be treated as having been or as being an eligible person for the purposes of this Act. (2) The Minister may, by legislative instrument, make an order declaring that, notwithstanding anything in this Act, a specified person, or every person included in a specified class of persons, being a person who, but for this subsection, would be an eligible person for the purposes of this Act, shall, or shall in specified circumstances, be treated as if he or she were not an eligible person for the purposes of this Act. (4) Nothing in any other provision of this Act shall be taken, by implication, to limit the generality of this section.

Certain prescribed persons in Australia to be treated as eligible persons etc.

6A Certain prescribed persons in Australia to be treated as eligible persons etc.

(1) The regulations may provide that a person who: (a) holds a prescribed kind of temporary visa; or (b) holds a prescribed kind of temporary visa and is a member of a class of persons prescribed for the purposes of this section; is, subject to the regulations, to be treated as an eligible person for the purposes of this Act while he or she is in Australia. (2) Without limiting the generality of subsection (1), the regulations may provide for all or any of the following: (a) the periods within which a person is to be treated as an eligible person; (b) the circumstances in which a person is to be treated as an eligible person; (c) the professional services in relation to which the person is to be treated as an eligible person; (d) the professional services in relation to which the person is not to be treated as an eligible person.

Agreement for reciprocal treatment of visitors to Australia and other countries

7 Agreement for reciprocal treatment of visitors to Australia and other countries

(1) The Government of the Commonwealth may enter into an agreement with the Government of another country under which each Government agrees to arrange for visitors to the country of that Government from the country of that other Government to be treated, for the purpose of the provision of medical, hospital and other care, as if they were residents or citizens of the country of that Government. (2) A visitor to Australia to whom an agreement under subsection (1) relates shall, subject to the agreement, be treated as an eligible person for the purposes of this Act during his or her stay in Australia.

External Territories

7A External Territories

This Act extends to Norfolk Island, to the Territory of Cocos (Keeling) Islands and to the Territory of Christmas Island.

Application of the Criminal Code

7B Application of the Criminal Code

Chapter 2 of the Criminal Code applies to all offences against this Act.

Note: Chapter 2 of the Criminal Code sets out the general principles of criminal responsibility.

Part II

Medicare benefits

Part II—Medicare benefits

Interpretation

8 Interpretation

(1A) In this Part, unless the contrary intention appears:

benefit means a Medicare benefit.

concessional person: a person is a concessional person in relation to a year at all times after the first time in that year that the person is a concessional beneficiary for the purposes of Part VII of the National Health Act 1953 (which deals with pharmaceutical benefits).

concessional safety‑net amount means $500.

Note: The concessional safety‑net amount is indexed under section 10A.

extended general safety‑net amount means $2,000.

Note: The extended general safety‑net amount is indexed under section 10A.

FTB(A) family: a registered family is an FTB(A) family in relation to a year (the safety‑net year) at all times:

(a) after the first time in the safety‑net year that a member of the family receives a payment of an instalment of family tax benefit under section 23 of the A New Tax System (Family Assistance) (Administration) Act 1999 that has a Part A rate that is greater than nil; or
(b) after a member of the family receives a payment of family tax benefit under section 24 of the A New Tax System (Family Assistance) (Administration) Act 1999 that has a Part A rate that is greater than nil and that is in respect of the last income year (within the meaning of that Act) ending before the start of the safety‑net year; or
(c) if a determination for the purposes of this paragraph is in force under section 8A—after the time specified in, or worked out in accordance with, the determination.

Note: The Part A rate is calculated under Schedule 1 to the A New Tax System (Family Assistance) Act 1999.

FTB(A) safety‑net amount means $500.

Note: The FTB(A) safety‑net amount is indexed under section 10A.

patient contribution, in relation to a claim for benefit in respect of a service, means an amount equal to the difference between:

(a) the Schedule fee or, if the medical expenses in respect of the service are less than that fee, those expenses; and
(b) the amount of benefit that, apart from section 10AC, 10ACA, 10AD or 10ADA (whichever is appropriate), would be payable in respect of the service, disregarding section 19AD.

registered family means a family registered under section 10AA.

safety‑net amount means $246.

Note: The safety‑net amount is indexed under section 10A.

Schedule fee, in relation to a service, means the fee specified in the table in respect of the service.

service means a professional service.

(1) For the purposes of this Part, an internal Territory shall be deemed to form part of the State of New South Wales. (2) For the purposes of this Part, Norfolk Island is taken to form part of the State of New South Wales.

Minister may determine registered family is FTB(A) family

8A Minister may determine registered family is FTB(A) family

(1) The Minister may, by legislative instrument, determine that a registered family is an FTB(A) family for the purposes of paragraph (c) of the definition of FTB(A) family in subsection 8(1A). (2) The determination must specify the time, or how to work out the time, after which the registered family is an FTB(A) family for the purposes of the paragraph.

Medicare benefits calculated by reference to fees

9 Medicare benefits calculated by reference to fees

Medicare benefits under this Part (other than sections 10ACA and 10ADA) shall be calculated by reference to the fees for medical services set out in the table.

Entitlement to Medicare benefit

10 Entitlement to Medicare benefit

(1) Where, on or after 1 February 1984, medical expenses are incurred in respect of a professional service rendered in Australia to an eligible person, medicare benefit calculated in accordance with subsection (2) is payable, subject to and in accordance with this Act, in respect of that professional service.

Note: For eligible person, medical expenses, medicare benefit and professional service see subsection 3(1).

(1A) For the purposes of subsection (1), a professional service that has, whether before or after the commencement of this subsection, been rendered to an eligible person in the course of a domestic journey is taken to have been rendered in Australia even if the person was outside Australia when the service was rendered. (1B) In subsection (1A):

domestic journey means a journey beginning at a place in Australia and ending at the same place, or at another place in Australia, without any intermediate stopping place outside Australia, and includes:

(a) such a journey that, when it began, was intended to end at a place outside Australia; and
(b) such a journey that is a part of a longer journey ending, or intended to end, at a place outside Australia; and
(c) such a journey that is part of a longer journey that began outside Australia.

(2) A benefit in respect of a service is: (a) in the case of a service provided: (i) as part of an episode of hospital treatment; or (ii) as part of an episode of hospital‑substitute treatment in respect of which the person to whom the treatment is provided chooses to receive a benefit from a private health insurer; an amount equal to 75% of the Schedule fee; or (aa) in the case of a service to which paragraph (a) does not apply and that is prescribed by the regulations for the purposes of this paragraph—an amount equal to 100% of the Schedule fee; or (b) in any other case—an amount equal to 85% of the Schedule fee. (2A) Without limiting the generality of regulations for the purposes of paragraph (2)(aa), the regulations may prescribe services for the purposes of that paragraph by identifying, in the table, the services concerned. (3) If the Schedule fee exceeds the amount of benefit calculated under paragraph (2)(b) by more than the greatest permissible gap, the benefit is taken to be the Schedule fee less the greatest permissible gap. (4) If an amount calculated under subsection (2) is not a multiple of 5 cents, that amount is to be rounded up to the nearest multiple of 5 cents. (5) In this section:

greatest permissible gap means $50.00.

10AA

Registered families

10AA Registered families

(1) For the purposes of this section and sections 10AB to 10AE inclusive, the following are the members of a person’s family: (a) the person’s spouse; (b) any dependent child of the person or of the person’s spouse. (2) Subject to subsection (3), a family member may apply to the Chief Executive Medicare at any time, in accordance with a form approved by the Chief Executive Medicare, for registration of the family, and the Chief Executive Medicare must register the family accordingly. (3) An application for registration must list the names of all family members. (4) If, at any time, a person becomes a member of a registered family, that person, or any family member acting on that person’s behalf, may apply to the Chief Executive Medicare in accordance with a form approved by the Chief Executive Medicare, for a variation in the registration to add the new family member, and the Chief Executive Medicare must vary the registration accordingly. (5) If, at any time, a person ceases to be a member of a registered family, that person, or any family member acting on that person’s behalf, may apply to the Chief Executive Medicare, in accordance with a form approved by the Chief Executive Medicare, for a variation in the registration to delete that person, and the Chief Executive Medicare must vary the registration accordingly. (6) A person is not entitled to be simultaneously treated as a member of more than one registered family unless: (a) the person is a child; and (b) the person is a dependent child in relation to persons in more than one registered family. (7) In this section:

child means a person who:

(a) is under 16; or
(b) is a student child.

dependent child, in relation to any person, means:

(a) a child under 16 who is:
(i) in the custody, care and control of that person; or
(ii) where no other person has the custody, care and control of the child—is wholly or substantially in the care and control of the first‑mentioned person; or
(b) a student child who is wholly or substantially dependent on the person.

spouse, in relation to a person, means:

(a) a person who is legally married to, and is not living, on a permanent basis, separately and apart from, that person; and
(b) a de facto partner of the person who is not living, on a permanent basis, separately and apart from the person.

student child means a person who:

(a) is 16 or more, but under 25; and
(b) is receiving full‑time education at a school, college or university.

10AB

Consequences of altered family composition

10AB Consequences of altered family composition

(1) Where: (a) a family is registered; and (b) a person becomes a family member after it is so registered; and (c) the family’s registration is varied by the addition of the new family member; then: (d) claims in respect of his or her medical expenses incurred during the calendar year in which the registration is varied but before the variation may be taken into account for the purposes of section 10AC or 10ACA as if the person had, at all times during that year, been a member of the registered family; but (e) increased benefits are not payable under that section in relation to medical expenses that are incurred in respect of that person or any other family member and in respect of which benefit has already been paid. (2) Where: (a) a family is registered; and (b) a person ceases to be a family member after it is so registered; and (c) the family’s registration is varied by the deletion of the person; and (d) the family members (including the person referred to in paragraph (b)) have not, at the time of the variation, become entitled under section 10AC or 10ACA to increased benefits in respect of medical expenses incurred in the calendar year in which the variation is made; claims in respect of his or her medical expenses incurred during that year may be dealt with separately under sections 10AD and 10ADA, or, if the person becomes a member of another registered family, dealt with under sections 10AC and 10ACA. (3) Where: (a) a family is registered; and (b) the family members become entitled under section 10AC or 10ACA to increased benefits in respect of medical expenses incurred in a year; and (c) a person ceases to be a family member after the family members become so entitled and during that year; and (d) the family’s registration is varied by the deletion of the person; then: (e) claims in respect of his or her medical expenses incurred at any time during that year are to be dealt with under sections 10AC and 10ACA, as if he or she had remained a family member throughout the year; and (f) despite any other provision of this Act and despite the variation, the person is not entitled to be treated as a member of another registered family during the year.

10AC

Safety‑net—families

10AC Safety‑net—families

(1) In this section:

relevant service means a service:

(a) in respect of which benefit is payable; and
(b) the medical expenses in respect of which exceed the amount of benefit that, apart from this section, would be payable in respect of the service;

but does not include a service rendered to a person while hospital treatment, or hospital‑substitute treatment in respect of which the person chooses to receive a benefit from a private health insurer, is provided to the person, being a service of that kind provided on or after 1 September 1985.

year means the year beginning on 1 January 1992 or a later year beginning on 1 January.

(2) Subject to this Act, if: (a) a claim (in this subsection called the threshold claim) for benefit is made by a claimant in respect of a relevant service: (i) which was rendered to the claimant or to a member of the claimant’s registered family; and (ii) in respect of which the medical expenses are incurred in a year; and the claim is accepted by the Chief Executive Medicare; and (b) other claims (in this subsection called prior claims) have been made for benefit in respect of relevant services: (i) which were rendered to any member of the family; and (ii) in respect of which the medical expenses were incurred during the year; and the prior claims were accepted for payment by the Chief Executive Medicare before the time when the threshold claim was accepted for payment (in this subsection called the relevant time); and (c) the Chief Executive Medicare is satisfied at the relevant time that: (i) the medical expenses of the services relating to the threshold claim and to some or all of the prior claims have been paid; and (ii) the sum of the patient contributions that have been paid in respect of those prior claims is less than the safety‑net amount for that year; and (iii) the sum of the patient contribution in respect of the threshold claim and the patient contributions referred to in subparagraph (ii) is equal to or exceeds the safety‑net amount; the benefit payable in respect of a relevant service rendered to any of the family and in respect of which medical expenses were incurred in respect of that year (being the service to which the threshold claim relates or any service that is not the subject of a prior claim referred to in paragraph (b)) is increased by the amount of the patient contribution in respect of that relevant service. (2A) The patient contributions under subparagraph (2)(c)(ii) (including for the purpose of subparagraph (2)(c)(iii)) are to be reduced by so much of those patient contributions as have been paid as increased benefits under section 10ACA. For this purpose, an amount of a patient contribution is taken to have been paid as an increased benefit under section 10ACA to the extent that the amount of the increase in the benefit payable for the relevant service exceeds the difference between the total medical expenses incurred in respect of the relevant service and the Schedule fee for the relevant service. (3) Where at any time a child is simultaneously a member of 2 families registered in respect of a year: (a) if the Chief Executive Medicare is satisfied that a medical expense incurred at that time in respect of the child has been incurred by an adult belonging to one or other of the families—that expense is to be treated, for the purposes of this Act, as an expense incurred in respect of the child as a member of that family; and (b) if the Chief Executive Medicare is not so satisfied—the expense is to be treated as an expense of which half was incurred in respect of the child as a member of one family and half in respect of the child as a member of the other family. (4) If a family becomes registered before 1 April 1992, this section extends to a benefit that was paid or payable before the registration in respect of a service for which medical expenses were incurred before that date. (5) If a family becomes registered after 31 March 1992, this section applies only to a benefit that becomes payable after the registration, even though expenses incurred before the registration in the year the family becomes registered may be taken into account for the purposes of paragraph (2)(c). (6) For the purposes of this section, without affecting the meaning of an expression in any other provision of this Act: (a) if a person to whom benefit is payable in respect of a relevant service is given or sent a cheque under subsection 20(2) or (2A) for the amount of the benefit, the person is taken to have paid so much of the medical expenses in respect of that service as is represented by the amount of the benefit; and (b) despite anything else in this Act, the question when medical expenses are incurred in respect of services relating to prescribed items is to be determined under the regulations. (7) For the purposes of this section, disregard section 19AD when determining whether medicare benefit is payable. However, this section does not authorise payment of medicare benefit contrary to section 19AD.

10ACA

Extended safety‑net—families

10ACA Extended safety‑net—families

(1) In this section:

relevant service means a service:

(a) in respect of which benefit is payable; and
(b) the medical expenses in respect of which exceed the amount of benefit that, apart from this section, would be payable in respect of the service;

year means a calendar year.

(2) Subject to this Act, if this section applies to a claim (the current claim), the benefit payable in respect of the claim is increased by 80% of the out‑of‑pocket expenses for the current claim. (3) The out‑of‑pocket expenses for a claim are: (a) the medical expenses incurred in respect of a relevant service for which the claim is made; reduced by: (b) any amounts payable under any other section of this Act in respect of those expenses. (4) This section applies to the current claim if: (a) the current claim is a claim that is made by a claimant for a benefit in respect of a relevant service which was rendered to the claimant or to a member of the claimant’s registered family; and (b) the medical expenses incurred in respect of the relevant service are incurred in a year (the expense year); and (c) the claimant has paid at least 20% of the out‑of‑pocket expenses for the service directly to the person by whom, or on whose behalf, the service was rendered; and (d) the current claim is accepted by the Chief Executive Medicare; and (e) one or more of the following apply to the claim: (i) the person to whom the service was rendered is a concessional person in relation to the expense year at the time that the claim is made and the concessional safety‑net applies to the current claim; (ii) the person to whom the service was rendered is a member of an FTB(A) family in relation to the expense year at the time that the claim is made and the FTB(A) safety‑net applies to the current claim; (iii) the extended general safety‑net applies to the current claim.

Note: Subsection 10AC(3) deals with a person being a member of more than one family.

(5) A safety‑net mentioned in paragraph (4)(e) applies to the current claim if the Chief Executive Medicare is satisfied at the time when the current claim was accepted for payment that the sum of the out‑of‑pocket expenses for the current claim and all relevant prior claims for a safety‑net for the expense year is equal to or exceeds the applicable safety‑net amount. (6) A claim is a relevant prior claim for a safety‑net for the expense year if: (a) the claim has been made for benefit in respect of relevant services which were rendered to: (i) for the concessional safety‑net—any member of the family who is a concessional person in relation to the expense year at the time that the current claim is made; and (ii) for the FTB(A) safety‑net or the extended general safety‑net—any person who is a member of the family at the time that the current claim is made; and (b) the claim is related to medical expenses incurred during the expense year; and (c) the claim was accepted for payment by the Chief Executive Medicare before the time when the current claim was accepted for payment; and (d) the Chief Executive Medicare is satisfied at the time when the current claim was accepted for payment that the out‑of‑pocket expenses for the claim have been paid. (7) If: (a) this section applies to the current claim; but (b) the sum of the out‑of‑pocket expenses for all relevant prior claims for the expense year is less than the applicable safety‑net amount; the benefit payable in respect of the claim is not increased under subsection (2) but is instead increased by the amount worked out using the formula:

Start formula 80% times open bracket Out-of-pocket expenses for current claim minus Balance of safety-net close bracket end formula

where:

balance of safety‑net means the amount by which the sum of the out‑of‑pocket expenses for all relevant prior claims for the expense year is less than the applicable safety‑net amount.

(7A) Despite subsections (2) and (7), if the current claim is for a service specified in an item determined under section 10B to be an item to which this subsection applies, the increase under this section in the benefit payable in respect of the claim cannot exceed the amount determined under section 10B as the maximum increase for that item.

Note: This subsection does not limit the increase payable in respect of a claim for a service specified in an item not determined under section 10B to be an item to which this subsection applies.

(7AA) If: (a) 2 or more services (the original services) that are each specified in an item are deemed to constitute, or are treated as, one service (the deemed service) under this Act (other than a provision of this Act prescribed by the regulations); and (b) all of the items in which the original services are specified are items determined under section 10B to be items to which subsection (7A) of this section applies; and (c) the current claim is for the deemed service; then, despite subsections (2) and (7) of this section, the increase under this section in the benefit payable in respect of the claim cannot exceed the sum of the amounts determined under section 10B as the maximum increases for those items.

Note: For when 2 or more services are deemed to constitute one service, see sections 15 and 16.

(7B) If: (a) for the purposes of the pathology services table: (i) 2 or more pathology services are treated as a single pathology service; and (ii) the fee for the single service is the fee specified in one or more particular items in the table; and (b) one or more of those particular items (the limited increase items) are items determined under section 10B to be items to which subsection (7A) of this section applies; then, for the purposes of that subsection, the single service is taken to be specified in the limited increase item or, if there are 2 or more limited increase items, in the one of those items for which the maximum increase determined under section 10B is the greatest.

Note: Section 4B lets regulations provide for a rule of interpretation of the pathology services table to treat 2 or more pathology services as a single pathology service.

(8) This section applies only to a benefit that becomes payable after a family becomes registered, even though expenses incurred before the registration in the year the family becomes registered may be taken into account for the purposes of determining whether a safety‑net applies. (9) For the purposes of this section (other than paragraph (4)(c)), without affecting the meaning of an expression in any other provision of this Act, if a person to whom benefit is payable in respect of a relevant service is given or sent a cheque under subsection 20(2) or (2A) for the amount of the benefit, the person is taken to have paid so much of the medical expenses in respect of that service as is represented by the amount of the benefit. (10) For the purposes of this section, without affecting the meaning of an expression in any other provision of this Act, despite anything else in this Act, the question when medical expenses are incurred in respect of relevant services relating to prescribed items is to be determined under the regulations. (11) For the purposes of this section, disregard section 19AD when determining whether medicare benefit is payable. However, this section does not authorise payment of medicare benefit contrary to section 19AD.

10AD

Safety‑net—individuals

10AD Safety‑net—individuals

(1) Expressions used in this section have the same meaning as in section 10AC. (2) Subject to subsection 10AB(3), this section applies to a person who is not a member of a registered family. (3) Subject to this Act, if: (a) a claim (in this subsection called the threshold claim) for benefit is made by a claimant in respect of a relevant service: (i) which was rendered to the claimant; and (ii) in respect of which the medical expenses are incurred by the claimant in a year; and the claim is accepted by the Chief Executive Medicare; and (b) the claimant has made other claims (in this subsection called the prior claims) for benefit in respect of relevant services: (i) which were rendered to the claimant; and (ii) in respect of which the medical expenses were incurred in that year; and the prior claims were accepted for payment by the Chief Executive Medicare before the time when the threshold claim was accepted for payment (in this subsection called the relevant time); and (c) the Chief Executive Medicare is satisfied at the relevant time that: (i) the medical expenses of the services relating to the threshold claim and some or all of the prior claims have been paid; and (ii) the sum of the patient contributions that have been paid in respect of those prior claims is less than the safety‑net amount for that year; and (iii) the sum of the patient contribution in respect of the threshold claim and the patient contributions referred to in subparagraph (ii) is equal to or exceeds the safety‑net amount; the benefit payable in respect of a relevant service rendered to the claimant and in respect of which medical expenses were incurred in respect of that year (being the service to which the threshold claim relates or any service that is not the subject of a prior claim referred to in paragraph (b)) is increased by the amount of the patient contribution in respect of that service. (3A) The patient contributions under subparagraph (3)(c)(ii) (including for the purpose of paragraph (3)(c)(iii)) are to be reduced by so much of those patient contributions as have been paid as increased benefits under section 10ADA. For this purpose, an amount of a patient contribution is taken to have been paid as an increased benefit under section 10ADA to the extent that the amount of the increase in the benefit payable for the relevant service exceeds the difference between the total medical expenses incurred in respect of the relevant service and the Schedule fee for the relevant service. (4) For the purposes of this section, without affecting the meaning of an expression in any other provision of this Act: (a) if a person to whom benefit is payable in respect of a relevant service is given or sent a cheque under subsection 20(2) or (2A) for the amount of the benefit, the person is taken to have paid so much of the medical expenses in respect of that service as is represented by the amount of the benefit; and (b) despite anything else in this Act, the question when medical expenses are incurred in respect of relevant services relating to prescribed items is to be determined under the regulations. (5) For the purposes of this section, disregard section 19AD when determining whether medicare benefit is payable. However, this section does not authorise payment of medicare benefit contrary to section 19AD.

10ADA

Extended safety‑net—individuals

10ADA Extended safety‑net—individuals

(1) Expressions used in this section have the same meaning as in section 10ACA. (2) Subject to subsection 10AB(3), this section applies to a person who is not a member of a registered family. (3) Subject to this Act, if this section applies to a claim (the current claim), the benefit payable in respect of the claim is increased by 80% of the out‑of‑pocket expenses for the current claim. (4) The out‑of‑pocket expenses for a claim are: (a) the medical expenses incurred in respect of a relevant service for which the claim is made; reduced by: (b) any amounts payable under any other section of this Act in respect of those expenses. (5) This section applies to the current claim if: (a) the current claim is a claim that is made by the person for a benefit in respect of a relevant service which was rendered to the person; and (b) the medical expenses incurred in respect of the relevant service are incurred in a year (the expense year); and (c) the person has paid at least 20% of the out‑of‑pocket expenses for the service directly to the person by whom, or on whose behalf, the service was rendered; and (d) the current claim is accepted by the Chief Executive Medicare; and (e) one or more of the following apply to the claim: (i) the person is a concessional person in relation to the expense year at the time that the claim is made and the concessional safety‑net applies to the current claim; (ii) the extended general safety‑net applies to the current claim. (6) A safety‑net mentioned in paragraph (5)(e) applies to the current claim if the Chief Executive Medicare is satisfied at the time when the current claim was accepted for payment that the sum of the out‑of‑pocket expenses for the current claim and all relevant prior claims for the expense year is equal to or exceeds the applicable safety‑net amount. (7) A claim is a relevant prior claim for the expense year if: (a) the claim has been made for benefit in respect of relevant services which were rendered to the person; and (b) the claim is related to medical expenses incurred during the expense year; and (c) the claim was accepted for payment by the Chief Executive Medicare before the time when the current claim was accepted for payment; and (d) the Chief Executive Medicare is satisfied at the time when the current claim was accepted for payment that the out‑of‑pocket expenses for the claim have been paid. (8) If: (a) this section applies to the current claim; but (b) the sum of the out‑of‑pocket expenses for all relevant prior claims for the expense year is less than the applicable safety‑net amount; the benefit payable in respect of the claim is not increased under subsection (3) but is instead increased by the amount worked out using the formula:

Start formula 80% times open bracket Out-of-pocket expenses for current claim minus Balance of safety-net close bracket end formula

where:

balance of safety‑net means the amount by which the sum of the out‑of‑pocket expenses for all relevant prior claims for the expense year is less than the applicable safety‑net amount.

(8A) Despite subsections (3) and (8), if the current claim is for a service specified in an item determined under section 10B to be an item to which this subsection applies, the increase under this section in the benefit payable in respect of the claim cannot exceed the amount determined under section 10B as the maximum increase for that item.

Note: This subsection does not limit the increase payable in respect of a claim for a service specified in an item not determined under section 10B to be an item to which this subsection applies.

(8AA) If: (a) 2 or more services (the original services) that are each specified in an item are deemed to constitute, or are treated as, one service (the deemed service) under this Act (other than a provision of this Act prescribed by the regulations); and (b) all of the items in which the original services are specified are items determined under section 10B to be items to which subsection (8A) of this section applies; and (c) the current claim is for the deemed service; then, despite subsections (3) and (8) of this section, the increase under this section in the benefit payable in respect of the claim cannot exceed the sum of the amounts determined under section 10B as the maximum increases for those items.

Note: For when 2 or more services are deemed to constitute one service, see sections 15 and 16.

(8B) If: (a) for the purposes of the pathology services table: (i) 2 or more pathology services are treated as a single pathology service; and (ii) the fee for the single service is the fee specified in one or more particular items in the table; and (b) one or more of those particular items (the limited increase items) are items determined under section 10B to be items to which subsection (8A) of this section applies; then, for the purposes of that subsection, the single service is taken to be specified in the limited increase item or, if there are 2 or more limited increase items, in the one of those items for which the maximum increase determined under section 10B is the greatest.

Note: Section 4B lets regulations provide for a rule of interpretation of the pathology services table to treat 2 or more pathology services as a single pathology service.

(9) For the purposes of this section (other than paragraph (5)(c)), without affecting the meaning of an expression in any other provision of this Act, if a person to whom benefit is payable in respect of a relevant service is given or sent a cheque under subsection 20(2) or (2A) for the amount of the benefit, the person is taken to have paid so much of the medical expenses in respect of that service as is represented by the amount of the benefit. (10) For the purposes of this section, without affecting the meaning of an expression in any other provision of this Act, despite anything else in this Act, the question when medical expenses are incurred in respect of relevant services relating to prescribed items is to be determined under the regulations. (11) For the purposes of this section, disregard section 19AD when determining whether medicare benefit is payable. However, this section does not authorise payment of medicare benefit contrary to section 19AD.

10AE

Confirmation of family composition

10AE Confirmation of family composition

(1) If the Chief Executive Medicare is satisfied that, apart from this section, a registered family would be, or would be likely soon to become, entitled to increased benefits under subsection 10AC or 10ACA in respect of a calendar year, the Chief Executive Medicare must request that the person who registered the family or another family member state, in a manner approved by the Chief Executive Medicare, whether or not: (a) the composition of the family remains, or (if the year has already ended) remained, in that year, as originally registered under section 10AA; or (b) if, after the registration, the Chief Executive Medicare has been notified of a change in the family composition—the composition of the family remains, or (if that year has already ended) remained, in that year, as last notified to the Chief Executive Medicare. (2) Until a family member provides the information sought under subsection (1), then, despite section 10AC or 10ACA, increased benefits are not payable in respect of the family members in respect of the year for which the confirmation was sought.

10A

Indexation

10A Indexation

(1) In this section:

index number, in relation to a quarter, means the All Groups Consumer Price Index number that is the weighted average of the 8 capital cities and is published by the Australian Statistician in respect of that quarter.

year means:

(b) for the purpose of the indexation of the amount of the greatest permissible gap—the year beginning on 1 November 1992 or a later year beginning on 1 November; or
(c) for the purpose of the indexation of the safety‑net amount—the year beginning on 1 January 1993 or a later year beginning on 1 January; or
(d) for the purpose of the indexation of the concessional safety‑net amount, the FTB(A) safety‑net amount and the extended general safety‑net amount—the year beginning on 1 January 2007 or a later year beginning on 1 January.

Note 1: greatest permissible gap is defined in subsection 10(5).

(2) The amount referred to in an item in the CPI Indexation Table below is to be indexed under this section every year on the indexation day specified in that item by using the reference quarter in that item.

<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><thead><tr><td colspan="4" style="width:354pt; border-top:1.5pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span style="font-weight:bold">CPI Indexation table</span></p><p class="Tabletext"><span style="font-weight:bold"></span></p></td></tr><tr><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span style="font-weight:bold">Item</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span style="font-weight:bold">Amount</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span style="font-weight:bold">Indexation day</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span style="font-weight:bold">Reference quarter</span></p></td></tr></thead><tbody><tr><td style="width:80.4pt; border-top:1.5pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>2.</span></p></td><td style="width:80.4pt; border-top:1.5pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>The amount of the greatest permissible gap</span></p></td><td style="width:80.4pt; border-top:1.5pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>1</span><span> </span><span>November</span></p></td><td style="width:80.4pt; border-top:1.5pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>June</span></p></td></tr><tr><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>3.</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>The safety</span><span>‑</span><span>net amount</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>1</span><span> </span><span>January</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>September</span></p></td></tr><tr><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext" style="page-break-after:avoid"><span>4.</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext" style="page-break-after:avoid"><span>The concessional safety</span><span>‑</span><span>net amount</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext" style="page-break-after:avoid"><span>1</span><span> </span><span>January</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext" style="page-break-after:avoid"><span>September</span></p></td></tr><tr><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>5.</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>The FTB(A) safety</span><span>‑</span><span>net amount</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>1</span><span> </span><span>January</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext"><span>September</span></p></td></tr><tr><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext" style="page-break-after:avoid"><span>6.</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext" style="page-break-after:avoid"><span>The extended general safety</span><span>‑</span><span>net amount</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext" style="page-break-after:avoid"><span>1</span><span> </span><span>January</span></p></td><td style="width:80.4pt; border-top:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p class="Tabletext" style="page-break-after:avoid"><span>September</span></p></td></tr></tbody></table>

(3) Where an amount is to be indexed on an indexation day, this Act has effect as if the indexed amount were substituted for that amount on that day. (4) The indexed amount for an amount to be indexed is: (a) the amount worked out by multiplying the amount to be indexed by the indexation factor for that amount; or (b) if the amount worked out under paragraph (a) is not a multiple of 10 cents—that amount rounded down to the nearest multiple of 10 cents. (5) Subject to subsections (6), (7) and (8), the indexation factor for an amount to be indexed on an indexation day is the amount worked out by using the formula:

Start formula start fraction Most recent index number over Previous index number end fraction end formula

where:

Most recent index number means the index number for the last quarter before the indexation day that is a reference quarter for the indexation of the amount; and

Previous index number, in relation to the indexation of an amount referred to in an item in the CPI Indexation Table in subsection (2), means the index number for the reference quarter in that item immediately before the most recent reference quarter in that item ending before the indexation day.

(6) An indexation factor is to be worked out to 3 decimal places. (7) If an indexation factor worked out under subsections (5) and (6) would, if it were worked out to 4 decimal places, end in a number that is greater than 4, the indexation factor is to be increased by 0.001. (8) If an indexation factor worked out under subsections (5), (6) and (7) would be less than 1, the indexation factor is to be increased to 1. (9) Subject to subsection (10), if at any time (whether before or after the commencement of this section), the Australian Statistician publishes an index number for a quarter in substitution for an index number previously published by the Statistician for that quarter, the publication of the later index number is to be disregarded for the purposes of this section. (10) If at any time (whether before or after the commencement of this section) the Australian Statistician changes the index reference period for the Consumer Price Index, regard is to be had, for the purposes of applying this section after the change takes place, only to index numbers published in terms of the new index reference period.

10B

Determinations for subsections 10ACA(7A) and 10ADA(8A)

10B Determinations for subsections 10ACA(7A) and 10ADA(8A)

(1) The Minister may by legislative instrument do either or both of the following: (a) determine that subsections 10ACA(7A) and 10ADA(8A) apply to specified items; (b) determine amounts as the maximum increases for items to which subsections 10ACA(7A) and 10ADA(8A) are determined to apply.

Note: For specification by class, see subsection 13(3) of the Legislation Act 2003.

(2) A determination made under subsection (1) does not come into effect until it has been approved by resolution of each House of the Parliament.

Medicare benefit not to exceed medical expenses incurred

14 Medicare benefit not to exceed medical expenses incurred

(1) A medicare benefit payable in respect of a professional service shall not exceed the medical expenses incurred in respect of the professional service. (2) Subsection (1) does not apply if: (a) the rendering of the professional service is covered by an agreement between a private health insurer and another person; and (b) the amount payable under the agreement for the professional service is not determined on a fee for service basis.

Medicare benefit in respect of 2 or more operations

15 Medicare benefit in respect of 2 or more operations

(1) Subject to this section, for the purpose of ascertaining whether medicare benefit is payable, or calculating the amount of a medicare benefit payable, in respect of the medical expenses incurred in respect of two or more operations, each constituting a professional service covered by an item, that are performed on the one occasion on the one person: (a) the amount specified in those items as fees, other than the greater or greatest of those amounts, shall be deemed to be reduced, as follows: (i) the greater or greatest of the amounts to be deemed to be reduced shall be deemed to be reduced by one‑half; and (ii) the other amount, or each of the other amounts, to be deemed to be reduced shall be deemed to be reduced by three‑quarters; and (b) the operations shall be deemed to constitute one professional service in respect of which the fee specified in the table in relation to the State in which the service was rendered is an amount equal to the aggregate of the amounts specified as fees in the items relating to those operations, being those amounts as reduced in accordance with paragraph (a). (2) For the purposes of paragraph (1)(a): (a) where two or more amounts referred to in that subsection are equal, one of those amounts shall be treated as being greater than the other or others of those amounts; and (b) where, by virtue of a reduction in accordance with that subsection, an amount is not a multiple of 5 cents, the amount of cents shall be increased to the nearest higher amount that is a multiple of 5 cents. (3) This section does not apply in relation to an operation, being one of two or more operations performed under the one anaesthetic on the one person, if the practitioner who performed the operation: (a) did not perform, or assist at, the other operation or any of the other operations; and (b) did not administer the anaesthetic. (4) In this section, operation does not include a medical service specified in an item in the general medical services table that relates to an amputation or a disarticulation of a limb.

Administration of anaesthetic and assistance at operation

16 Administration of anaesthetic and assistance at operation

(1) A medicare benefit is not, except with the approval of the Minister, payable in respect of the administration of an anaesthetic in connexion with a professional service unless the anaesthetic is administered by a practitioner other than the practitioner who renders the professional service in connexion with which the anaesthetic is administered. (2) A medicare benefit in respect of assistance at an operation is not payable if the assistance is rendered by the anaesthetist or a practitioner assisting the anaesthetist. (3) Where an item relates to a professional service constituted by: (a) assistance at an operation; (b) the administration of an anaesthetic; or (c) assistance in the administration of an anaesthetic; the amount of medicare benefit payable in respect of that professional service is the same whether the assistance is rendered, or the anaesthetic is administered, by one or more than one practitioner.

16A

Medicare benefits in relation to pathology services

16A Medicare benefits in relation to pathology services

(1) A medicare benefit is not payable in respect of a pathology service that has been rendered in relation to a person unless: (a) the service (whether a pathologist‑determinable service or not) was determined to be necessary by a practitioner (in this section referred to as the treating practitioner) whose patient the person was; or (aa) the service (whether a pathologist‑determinable service or not) was: (i) determined to be necessary by a participating midwife (in this section also referred to as the treating practitioner), acting in his or her capacity as a participating midwife, whose patient the person was; and (ii) a service of a kind specified in regulations made for the purposes of this subparagraph; or (ab) the service (whether a pathologist‑determinable service or not) was: (i) determined to be necessary by a participating nurse practitioner (in this section also referred to as the treating practitioner), acting in his or her capacity as a participating nurse practitioner, whose patient the person was; and (ii) a service of a kind specified in regulations made for the purposes of this subparagraph; or (b) the service was: (i) a pathologist‑determinable service rendered by or on behalf of an approved pathology practitioner; and (ii) determined to be necessary by that approved pathology practitioner. (2) A medicare benefit is not payable in respect of a pathology service (other than a prescribed pathology service to which subsection (7) or (7A) applies) unless: (a) the service was rendered by or on behalf of an approved pathology practitioner; (b) the service was rendered in an accredited pathology laboratory and was a service of a kind in respect of which the laboratory was accredited; (c) the proprietor of the laboratory was an approved pathology authority; (ca) there was no other proprietor of the laboratory; and (d) either: (i) the approved pathology practitioner by whom or on whose behalf the service was rendered was the proprietor of the laboratory; or (ii) the service was rendered in the laboratory under an agreement (whether by way of contract of employment or otherwise) between: (A) the approved pathology practitioner by whom or on whose behalf the pathology service was rendered; and (B) the proprietor of the laboratory. (3) A medicare benefit is not payable in respect of a pathology service (other than a pathologist‑determinable service to which subsection (6) applies) that has been rendered by or on behalf of an approved pathology practitioner unless: (a) the service was rendered pursuant to a request made by the treating practitioner and, if an approved pathology practitioner was specified on the request, the service was conducted by that practitioner; or (b) the service was rendered pursuant to a request made by another approved pathology practitioner who received a request for the service made by the treating practitioner and the treating practitioner did not specify a pathology practitioner. (3A) In subsection (3), a treating practitioner may only specify an approved pathology practitioner on clinical grounds. (4) A request is not effective for the purposes of subsection (3) unless: (a) the request is: (i) made in writing; or (ii) if made otherwise than in writing—confirmed in writing within the period of 14 days commencing on the day on which the request is made; and (b) the request is made in accordance with the regulations (if any). (5) A request that is made otherwise than in writing and is not confirmed in writing within the period referred to in subparagraph (4)(a)(ii) shall be deemed, for the purposes of subsection (3), never to have been made. (5AA) A medicare benefit is not payable in respect of a pathology service that has been rendered in relation to a person by or on behalf of an approved pathology practitioner (in subsection (5AB) called the rendering pathologist) pursuant to a request made by: (a) the treating practitioner; or (b) another approved pathology practitioner (in subsection (5AB) called the referring pathologist) who received a request for the service made by the treating practitioner; unless the pathology specimen required for the rendering of the service: (c) was collected from the person: (i) by the person himself or herself; or (ii) by the treating practitioner; or (iii) on behalf of the treating practitioner, by an employee of, or by a person engaged under a contract for services by or on behalf of, the treating practitioner; or (iv) if the treating practitioner is employed, or engaged under a contract for services, by a medical entrepreneur—on behalf of the treating practitioner, by another employee of that medical entrepreneur, or by a person engaged under a contract for services by or on behalf of that medical entrepreneur; or (d) was collected from the person by a person to whom this paragraph applies at: (i) the place where the person was residing; or (ii) an approved collection centre (within the meaning of Part IIA); or (iii) premises of a recognised hospital, being premises at which hospital treatment is provided; or (iv) a private hospital in which the person is a patient; or (v) a residential care home (within the meaning of the Aged Care Act 2024), or other institution, in which the person is receiving care; or (e) was collected from the person by: (i) a member of the staff of a hospital in which the person is a patient; or (ii) a member of the staff of a residential care home (within the meaning of the Aged Care Act 2024), or other institution, in which the person is receiving care. (5AB) Paragraph (5AA)(d) applies to: (a) the rendering pathologist; and (b) the referring pathologist (if any); and (c) an employee of an approved pathology authority that is the proprietor of the laboratory in which the service is to be rendered; and (d) an employee of an approved pathology authority from which the pathology specimen in question was referred to: (i) an approved pathology authority to which paragraph (c) applies; or (ii) an approved pathology practitioner who is to render the service in a laboratory of which such an approved pathology authority is the proprietor. (5A) A medicare benefit is not payable in respect of a pathology service that has been rendered by or on behalf of an approved pathology practitioner if: (a) the request for the service was made: (i) by the treating practitioner (the requesting practitioner); or (ii) by another approved pathology practitioner (the requesting practitioner) who received a request for the service made by the treating practitioner; and (b) the request for the service was made as a result of: (i) conduct in respect of which the approved pathology practitioner or the requesting practitioner has been convicted of an offence under Division 3 of Part IIBA; or (ii) conduct in respect of which the approved pathology practitioner or the requesting practitioner has been ordered to pay a pecuniary penalty under Part VIA. (6) This subsection applies to a pathology service if the service is a pathologist‑determinable service that is rendered by or on behalf of an approved pathology practitioner and the approved practitioner determines that the service is necessary. (7) This subsection applies to a pathology service if the service is a prescribed pathology service that is rendered by or on behalf of a medical practitioner (not being an approved pathology practitioner) and: (a) the medical practitioner by whom or on whose behalf the service is rendered is the treating practitioner; or (b) the medical practitioner by whom or on whose behalf the service is rendered: (i) is a member of a group of practitioners of which the treating practitioner is a member; and (ii) is requested by the treating practitioner to render the service. (7A) This subsection applies to a pathology service if: (a) the service is a prescribed pathology service that is rendered by a participating midwife or a participating nurse practitioner; and (b) the participating midwife or participating nurse practitioner by whom the service is rendered is the treating practitioner; and (c) the service is specified in the determination made under section 4BB as a service to which this subsection applies if rendered by a participating midwife or participating nurse practitioner (as the case requires); and (d) if that determination specifies circumstances in which the service must be rendered to be a pathology service to which this subsection applies—the service is rendered in those circumstances. (9) Where: (a) a practitioner conducts a medical practice or a dental practice; and (b) another practitioner, or other practitioners, participate (whether as employees or otherwise) in the provision of professional services as part of that practice; the practitioner referred to in paragraph (a) and the practitioner or practitioners referred to in paragraph (b) shall be taken, for the purposes of this section, to constitute a group of practitioners. (10) Where 2 or more practitioners conduct a medical practice or a dental practice as partners, those practitioners and any other practitioner who participates (whether as an employee or otherwise) in the provision of professional services as part of that practice, shall be taken, for the purposes of this section, to constitute a group of practitioners. (11) For the purposes of subsection (10), where 2 or more practitioners share amongst them all the income, or a substantial part of the income, from providing professional services, those practitioners shall be deemed to conduct a practice of providing those professional services as partners. (12) In this section: (a) a reference to a request made in writing or to a confirmation in writing of a request shall be read as including a reference to a request or a confirmation, as the case may be, in such other form as the Minister approves, in writing, from time to time; and (b) a reference to determining that a service is necessary is a reference to determining that a service is reasonably necessary for the adequate medical care of the patient concerned.

16B

Medicare benefits in relation to R‑type diagnostic imaging services

16B Medicare benefits in relation to R‑type diagnostic imaging services

General rule—request required for services (1) Subject to subsections (6), (7), (8), (9), (10) and (11), a medicare benefit is not payable in respect of an R‑type diagnostic imaging service rendered in relation to a person by or on behalf of a medical practitioner (in this section called the providing practitioner) unless: (a) where the service is one for which there is a corresponding NR‑type diagnostic imaging service: (i) the providing practitioner is a consultant physician, or a specialist, in a particular specialty; and (ii) the service was rendered by or on behalf of the providing practitioner in the course of the providing practitioner practising that specialty; and (b) the service was rendered pursuant to a written request made by: (i) another medical practitioner; or (ii) subject to subsection (2), a dental practitioner; or (iii) subject to subsection (3), a chiropractor; or (iv) subject to subsection (3A), a physiotherapist; or (v) subject to subsection (3B), a podiatrist; or (vi) subject to subsection (3C), an osteopath; or (vii) subject to subsection (3D), a participating midwife; or (viii) subject to subsection (3E), a participating nurse practitioner; who determined that the service was necessary and whose patient the person was. Dental practitioners may only request certain services (2) A request made by a dental practitioner, acting in his or her capacity as a dental practitioner, for an R‑type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection. Chiropractors may only request certain services (3) A request made by a chiropractor, acting in his or her capacity as a chiropractor, for an R‑type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection. Physiotherapists may only request certain services (3A) A request made by a physiotherapist, acting in his or her capacity as a physiotherapist, for an R‑type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection. Podiatrists may only request certain services (3B) A request made by a podiatrist, acting in his or her capacity as a podiatrist, for an R‑type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection. Osteopaths may only request certain services (3C) A request made by an osteopath, acting in his or her capacity as an osteopath, for an R‑type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection. Participating midwives may only request certain services (3D) A request made by a participating midwife, acting in his or her capacity as a participating midwife, for an R‑type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection. Participating nurse practitioners may only request certain services (3E) A request made by a participating nurse practitioner, acting in his or her capacity as a participating nurse practitioner, for an R‑type diagnostic imaging service to be rendered is not effective for the purposes of subsection (1) unless it is a request for a service of a kind specified in regulations made for the purposes of this subsection. Referral to specified practitioner not required (4) For the purposes of subsection (1): (a) the request need not be addressed to a particular practitioner; and (b) where it is so addressed—the service need not be rendered by or on behalf of that practitioner. Request may be for more than one service (5) For the purposes of subsection (1), the request may be for the rendering of more than one R‑type diagnostic imaging service, but, once one of the requested services has been rendered pursuant to the notice, any subsequent requested service is not taken to have been rendered pursuant to the notice unless it is so rendered within 7 days after the rendering of the first service. Exemption—consultant physicians and specialists (6) Subsection (1) does not apply if: (a) the providing practitioner is a consultant physician, or a specialist, in a particular specialty (other than the specialty of diagnostic radiology); and (b) the service was rendered by or on behalf of the providing practitioner in the course of the providing practitioner practising that specialty; and (c) the providing practitioner determined that the service was necessary. Remote area exemption (7) Subsection (1) does not apply if: (a) the service is not one for which there is a corresponding NR‑type diagnostic imaging service; and (b) the service was rendered within an area that is a remote area for the purposes of Division 2 of Part IIB; and (c) the service was rendered during the period when a remote area exemption granted to the providing practitioner under section 23DX was in force; and (d) if the remote area exemption in force in relation to the practitioner was restricted under subsection 23DY(1) to certain R‑type diagnostic imaging services—the service is one of those R‑type diagnostic imaging services; and (e) either: (i) the service was rendered before the end of one month (or such further period as the Chief Executive Medicare allows) after the commencement of this paragraph; or (ii) the service was rendered after the end of that period at a time when the practitioner was registered as a participating practitioner in the Register of Participating Practitioners maintained under section 23DSC. Exemption—emergencies (8) Subsection (1) does not apply if the providing practitioner determines that, because the need for the service arose in an emergency, the service should be rendered as quickly as possible. Exemption—lost requests (9) Subsection (1) does not apply if: (a) the person in relation to whom the service was rendered, or a person acting on that person’s behalf, claimed that a medical practitioner, dental practitioner, chiropractor, physiotherapist, podiatrist, osteopath, participating midwife or participating nurse practitioner, had made a request for the service to be rendered, but that the request had been lost; and (b) the providing practitioner, or an employee or agent of the providing practitioner, had sought and received from the medical practitioner, dental practitioner, chiropractor, physiotherapist, podiatrist, osteopath, participating midwife or participating nurse practitioner, (in this subsection called the requesting practitioner) who was claimed to have made the request, or from an employee or agent of the requesting practitioner, confirmation that the request had been made; and (c) if the requesting practitioner is a dental practitioner who made the request in his or her capacity as a dental practitioner—the request is not rendered ineffective by the operation of subsection (2); and (d) if the requesting practitioner is a chiropractor who made the request in his or her capacity as a chiropractor—the request is not rendered ineffective by the operation of subsection (3); and (e) if the requesting practitioner is a physiotherapist who made the request in his or her capacity as a physiotherapist—the request is not rendered ineffective by the operation of subsection (3A); and (f) if the requesting practitioner is a podiatrist who made the request in his or her capacity as a podiatrist—the request is not rendered ineffective by the operation of subsection (3B); and (g) if the requesting practitioner is an osteopath who made the request in his or her capacity as an osteopath—the request is not rendered ineffective by the operation of subsection (3C); and (h) if the requesting practitioner is a participating midwife who made the request in his or her capacity as a participating midwife—the request is not rendered ineffective by the operation of subsection (3D); and (i) if the requesting practitioner is a participating nurse practitioner who made the request in his or her capacity as a participating nurse practitioner—the request is not rendered ineffective by the operation of subsection (3E). Exemption—additional services (10) Subsection (1) does not apply if: (a) the diagnostic imaging service (the additional service) was rendered in relation to the person because the providing practitioner formed the opinion that the results obtained from the rendering of another diagnostic imaging service in relation to the person, pursuant to a subsection 16B(1) request, indicate that the additional service is necessary; and (b) the additional service is a service in relation to which a medicare benefit is payable (or would be payable if section 19AD were disregarded) regardless of whether the service is rendered on the request of a specialist or a consultant physician.

Note: Medicare benefit is only payable on some diagnostic imaging services if they are rendered on the request of a specialist or consultant physician. The additional service must not be one of those services.

Exemption—substituted services (10A) Subsection (1) does not apply if: (a) the diagnostic imaging service (the substituted service) was rendered in relation to the person in substitution for another service for which a subsection 16B(1) request has been made; and (b) the substituted service was rendered because the providing practitioner formed the opinion that it would be more appropriate in the diagnosis of the person’s condition to render the substituted service than the service requested; and (c) the substituted service would be accepted by the general body of specialists or consultant physicians in the specialty practised by the providing practitioner as more appropriate in the diagnosis of the person’s condition than the service requested; and (d) before providing the substituted service, the providing practitioner has either consulted the person who made the subsection 16B(1) request, or taken all reasonable steps to consult that person; and (e) the substituted service is a service in relation to which a medicare benefit is payable (or would be payable if section 19AD were disregarded) regardless of whether the service is rendered on the request of a specialist or a consultant physician.

Note: Medicare benefit is only payable on some diagnostic imaging services if they are rendered on the request of a specialist or consultant physician. The substituted service must not be one of those services.

Exemption—pre‑existing diagnostic imaging practices (11) Subsection (1) does not apply if: (a) the service is a service of a kind specified in regulations made for the purposes of this subsection; and (b) the service was rendered by or on behalf of the providing practitioner in the course of treating his or her own patient; and (c) the providing practitioner determined that the service was necessary; and (d) either: (i) the service was rendered before the end of one month (or such further period as the Chief Executive Medicare allows) after the commencement of this paragraph; or (ii) the service was rendered after the end of that period at a time when the practitioner was registered as a participating practitioner in the Register of Participating Practitioners maintained under section 23DSC; and (e) during the period commencing on 17 October 1988 and ending on 16 October 1990, at least 50 services had been rendered by or on behalf of the providing practitioner, each being a service that: (i) would have been an R‑type diagnostic imaging service if it had been rendered after the commencement of this section; and (ii) was rendered at the location at which the first‑mentioned service was rendered; and (iii) resulted in the payment of a medicare benefit.

16C

Medicare benefits in relation to diagnostic imaging services rendered in contravention of State or Territory laws

16C Medicare benefits in relation to diagnostic imaging services rendered in contravention of State or Territory laws

A medicare benefit is not payable in respect of a diagnostic imaging service rendered by or on behalf of a medical practitioner if the rendering of the service involved the contravention, by the practitioner or any other person, of any law of a State or Territory relating directly or indirectly to the use of diagnostic imaging procedures or diagnostic imaging equipment.

16D

Medicare benefits not payable for certain diagnostic imaging services: registration

16D Medicare benefits not payable for certain diagnostic imaging services: registration

(1) Unless the Minister otherwise directs, a medicare benefit is not payable in respect of a diagnostic imaging service rendered by or on behalf of a medical practitioner unless the diagnostic imaging procedure used in rendering that service is: (a) carried out using diagnostic imaging equipment that: (i) is ordinarily located at registered diagnostic imaging premises; and (ii) is of a type that, on the day on which the procedure is carried out, is listed for the premises; or (b) carried out using diagnostic imaging equipment that: (i) is ordinarily located at a registered base for mobile diagnostic imaging equipment when not in use; and (ii) is not ordinarily located at diagnostic imaging premises; and (iii) is of a type that, on the day on which the procedure is carried out, is listed for the base. Meaning of registered diagnostic imaging premises and registered base for mobile diagnostic imaging equipment (2) Diagnostic imaging premises are registered at a particular time if a registration for the premises under Division 4 of Part IIB is in effect at that time. (3) A base for mobile diagnostic imaging equipment is registered at a particular time if a registration for the base under Division 4 of Part IIB is in effect at that time. What equipment is listed for premises or a base? (4) Diagnostic imaging equipment is of a type listed for particular diagnostic imaging premises at a particular time if, at that time: (a) the Diagnostic Imaging Register states that equipment of a particular type is ordinarily located at the premises; and (b) the equipment is of that type. (5) Diagnostic imaging equipment is of a type listed for a particular base for mobile diagnostic imaging equipment at a particular time if, at that time: (a) the Diagnostic Imaging Register states that pieces of equipment of a particular type are ordinarily located at the base when not in use and not ordinarily located at diagnostic imaging premises; and (b) the equipment is of that type. Some circumstances in which diagnostic imaging equipment is taken to be ordinarily located at diagnostic imaging premises (6) Diagnostic imaging equipment is taken to be ordinarily located at diagnostic imaging premises if: (a) the equipment is: (i) on trial at the premises for a period of not more than 3 months; and (ii) of the same type as equipment listed for the premises during the period of the trial; or (b) each of the following circumstances exist: (i) the equipment (the substituted equipment) is used, for a period of not more than 3 months, in substitution for diagnostic imaging equipment that is not in operation; (ii) the substituted equipment is of the same type as the equipment that is not in operation; (iii) the equipment that is not in operation is ordinarily located at the premises. (7) Nothing in subsection (6) limits the circumstances in which diagnostic imaging equipment is ordinarily located at diagnostic imaging premises for the purposes of this Part or Division 4 or 5 of Part IIB. Some circumstances in which diagnostic imaging equipment is taken to be ordinarily located at a base for mobile diagnostic imaging equipment when not in use and not ordinarily located at diagnostic imaging premises (8) Diagnostic imaging equipment is taken to be ordinarily located at a base for mobile diagnostic imaging equipment when not in use, and not ordinarily located at diagnostic imaging premises, if: (a) the equipment is: (i) on trial through the base for a period of not more than 3 months; and (ii) not ordinarily located, or taken to be ordinarily located, at diagnostic imaging premises during the period of the trial; and (iii) of the same type as equipment listed for the base during the period of the trial; or (b) each of the following circumstances exist: (i) the equipment (the substituted equipment) is used, for a period of not more than 3 months, in substitution for diagnostic imaging equipment that is not in operation; (ii) the substituted equipment is of the same type as the equipment that is not in operation; (iii) the equipment that is not in operation is ordinarily located at the base when not in use and not ordinarily located at diagnostic imaging premises. (9) Nothing in subsection (8) limits the circumstances in which diagnostic imaging equipment is ordinarily located at a base for mobile diagnostic imaging equipment, but not ordinarily located at diagnostic imaging premises, for the purposes of this Part or Division 4 or 5 of Part IIB.

16E

Medicare benefit is payable once a suspension of a registration is lifted

16E Medicare benefit is payable once a suspension of a registration is lifted

If, but for this section, medicare benefit would not be payable in respect of a diagnostic imaging service rendered by or on behalf of a medical practitioner because the diagnostic imaging procedure used in rendering that service is: (a) carried out using diagnostic imaging equipment that is ordinarily located at diagnostic imaging premises the registration of which has been suspended; or (b) carried out using diagnostic imaging equipment that: (i) when not in use, is ordinarily located at a base for mobile diagnostic imaging equipment the registration of which is suspended; and (ii) is not ordinarily located at diagnostic imaging premises; medicare benefit becomes payable in respect of the service when the suspension ceases to have effect, provided the suspension does not cease to have effect because the registration is cancelled under section 23DZY.

16EA

Medicare benefits not payable for certain diagnostic imaging services: accreditation

16EA Medicare benefits not payable for certain diagnostic imaging services: accreditation

16F

Medicare benefits not payable for certain radiation oncology services

16F Medicare benefits not payable for certain radiation oncology services

(1) Unless the Minister otherwise directs, a medicare benefit is not payable in respect of a radiation oncology service rendered by or on behalf of a medical practitioner unless the service is: (a) rendered using radiation oncology equipment that: (i) is ordinarily located at registered radiation oncology premises; and (ii) is of a type that, on the day on which the service is rendered, is listed for the premises; or (b) rendered using radiation oncology equipment that: (i) is ordinarily located at a registered base for mobile radiation oncology equipment when not in use; and (ii) is not ordinarily located at radiation oncology premises; and (iii) is of a type that, on the day on which the service is rendered, is listed for the base. Meaning of radiation oncology service (2) A radiation oncology service is a service prescribed as a radiation oncology service. (3) Radiation oncology services may be prescribed by reference to items in the general medical services table. Meaning of registered radiation oncology premises and registered base for mobile radiation oncology equipment (4) Radiation oncology premises are registered at a particular time if a registration for the premises under Part IIC is in effect at that time. (5) A base for mobile radiation oncology equipment is registered at a particular time if a registration for the base under Part IIC is in effect at that time. What equipment is listed for premises or a base? (6) Radiation oncology equipment is of a type listed for particular radiation oncology premises at a particular time if, at that time: (a) the Radiation Oncology Register states that equipment of a particular type is ordinarily located at the premises; and (b) the equipment is of that type. (7) Radiation oncology equipment is of a type listed for a particular base for mobile radiation oncology equipment at a particular time if, at that time: (a) the Radiation Oncology Register states that pieces of equipment of a particular type are ordinarily located at the base when not in use and not ordinarily located at radiation oncology premises; and (b) the equipment is of that type. Some circumstances in which radiation oncology equipment is taken to be ordinarily located at radiation oncology premises (8) Radiation oncology equipment is taken to be ordinarily located at radiation oncology premises if: (a) the equipment is: (i) on trial at the premises for a period of not more than 3 months; and (ii) of the same type as equipment listed for the premises during the period of the trial; or (b) each of the following circumstances exist: (i) the equipment (the substituted equipment) is used, for a period of not more than 3 months, in substitution for radiation oncology equipment that is not in operation; (ii) the substituted equipment is of the same type as the equipment that is not in operation; (iii) the equipment that is not in operation is ordinarily located at the premises. (9) Nothing in subsection (8) limits the circumstances in which radiation oncology equipment is ordinarily located at radiation oncology premises for the purposes of this Part or Part IIC. Some circumstances in which radiation oncology equipment is taken to be ordinarily located at a base for mobile radiation oncology equipment when not in use and not ordinarily located at radiation oncology premises (10) Radiation oncology equipment is taken to be ordinarily located at a base for mobile radiation oncology equipment when not in use, and not ordinarily located at radiation oncology premises, if: (a) the equipment is: (i) on trial through the base for a period of not more than 3 months; and (ii) not ordinarily located, or taken to be ordinarily located, at radiation oncology premises during the period of the trial; and (iii) of the same type as equipment listed for the base during the period of the trial; or (b) each of the following circumstances exist: (i) the equipment (the substituted equipment) is used, for a period of not more than 3 months, in substitution for radiation oncology equipment that is not in operation; (ii) the substituted equipment is of the same type as the equipment that is not in operation; (iii) the equipment that is not in operation is ordinarily located at the base when not in use and not ordinarily located at radiation oncology premises. (11) Nothing in subsection (10) limits the circumstances in which radiation oncology equipment is ordinarily located at a base for mobile radiation oncology equipment, but not ordinarily located at radiation oncology premises, for the purposes of this Part or Part IIC.

16G

Medicare benefit is payable once a suspension of a registration is lifted

16G Medicare benefit is payable once a suspension of a registration is lifted

If, but for this section, medicare benefit would not be payable in respect of a radiation oncology service rendered by or on behalf of a medical practitioner because the service is: (a) rendered using radiation oncology equipment that is ordinarily located at radiation oncology premises the registration of which has been suspended; or (b) rendered using radiation oncology equipment that: (i) when not in use, is ordinarily located at a base for mobile radiation oncology equipment the registration of which is suspended; and (ii) is not ordinarily located at radiation oncology premises; medicare benefit becomes payable in respect of the service when the suspension ceases to have effect, provided the suspension does not cease to have effect because the registration is cancelled under section 23DZZX.

Medicare benefits not payable in respect of certain medical expenses

17 Medicare benefits not payable in respect of certain medical expenses

(1) A medicare benefit is not payable in respect of a professional service if: (a) the medical expenses in respect of that service have been paid, or are payable, to a recognized hospital; (b) the medical practitioner who rendered the service was acting on behalf of an organization that was, when the service was rendered, an organization prescribed for the purposes of this paragraph; (c) any part of the service was rendered on the premises of an organization that was, when the service was rendered, an organization referred to in paragraph (b); or (d) any amount has been paid, or is payable, in respect of the service in accordance with a scheme to which section 42B applies.

Medicare benefit not payable in respect of certain professional services

19 Medicare benefit not payable in respect of certain professional services

(1) A medicare benefit is not payable in respect of a professional service that is a medical examination for the purposes of: (a) life insurance; (b) superannuation or provident account schemes; or (c) admission to membership of a friendly society. (2) Unless the Minister otherwise directs, a medicare benefit is not payable in respect of a professional service that has been rendered by, or on behalf of, or under an arrangement with: (a) the Commonwealth; (b) a State; (c) a local governing body; or (d) an authority established by a law of the Commonwealth, a law of a State or a law of an internal Territory. (3) Unless the Minister otherwise directs, a medicare benefit is not payable in respect of a professional service rendered to a person if: (a) the medical expenses in respect of that professional service were incurred by the employer of that person; or (b) the person to whom that professional service was rendered was employed in an industrial undertaking and that professional service was rendered to him or her for purposes connected with the operation of that undertaking. (4) A medicare benefit is not payable in respect of a professional service rendered in the course of the carrying out of a mass immunization. (5) Unless the Minister otherwise directs, a medicare benefit is not payable in respect of a health screening service, that is to say, a professional service that is a medical examination or test that is not reasonably required for the management of the medical condition of the patient. (6) A medicare benefit is not payable in respect of a professional service unless the person by or on behalf of whom the professional service was rendered, or an employee of that person, has recorded on the account, or on the receipt, for fees in respect of the service or, if an assignment has been made, or an agreement has been entered into, in accordance with section 20A, in relation to the medicare benefit in respect of the service, on the form of the assignment or agreement, as the case may be, such particulars as are prescribed in relation to professional services generally or in relation to a class of professional services in which that professional service is included.

19AA

Medicare benefits not payable in respect of services rendered by certain medical practitioners

19AA Medicare benefits not payable in respect of services rendered by certain medical practitioners

(1) A medicare benefit is not payable in respect of a professional service, rendered after the commencement of this section, if the person who rendered the service: (a) first became a registered medical practitioner on or after 1 November 1996; and (b) was not, at the time the service was rendered: (i) a specialist (whether or not the service was rendered in the performance of the specialist’s specialty); or (ii) a consultant physician (whether or not the service was rendered in the performance of the consultant physician’s specialty); or (iii) a general practitioner; or

Note: For general practitioner, see subsection 3(1).

(iv) subject to subsection (3), a person registered under section 3GA; or
(v) a person who is covered by an exemption under subsection 19AB(3), being a person who is neither an Australian citizen nor a permanent resident within the meaning of the Migration Act 1958.

Note: Subsection (5) gives a restricted meaning to the term professional service for the purposes of this section.

(2) A medicare benefit is not payable in respect of a professional service, rendered after the commencement of this section, if the medical practitioner on whose behalf the service was rendered: (a) first became a registered medical practitioner on or after 1 November 1996; and (b) was not, at the time the service was rendered: (i) a specialist (whether or not the service was rendered in the performance of the specialist’s specialty); or (ii) a consultant physician (whether or not the service was rendered in the performance of the consultant physician’s specialty); or (iii) a general practitioner; or

Note: For general practitioner, see subsection 3(1).

(iv) subject to subsection (3), a person registered under section 3GA; or
(v) a person who is covered by an exemption under subsection 19AB(3), being a person who is neither an Australian citizen nor a permanent resident within the meaning of the Migration Act 1958.

Note 1: An effect of subsection 3(17) is that a service cannot be taken to be rendered on behalf of a medical practitioner if it is rendered by another medical practitioner.

Note 2: Subsection (5) gives a restricted meaning to the term professional service for the purposes of this section.

(3) Subparagraphs (1)(b)(iv) and (2)(b)(iv) only apply in relation to a professional service that was rendered: (a) during the period in respect of which, and in the location in respect of which, the person is registered under section 3GA; or (b) in such other circumstances (which may include circumstances relating to the period during which, or the location in which, services are rendered) as are specified in the regulations. (4) For the purposes of this section, a registered medical practitioner who, on 1 November 1996: (a) was a registered medical practitioner who had not commenced, or who had not completed, training as an intern; or (b) was not an Australian citizen or a permanent resident within the meaning of the Migration Act 1958; is taken to have first become a registered medical practitioner on 1 November 1996. (5) In this section:

intern means a registered medical practitioner who is undertaking:

(a) a period of internship (by whatever name called); or
(b) a period of supervised training (by whatever name called);

under a law of a State or Territory specified in the regulations (whether or not the registered medical practitioner is a resident in a hospital for some or all of that period).

professional service does not include:

(a) a service of a kind referred to in paragraph (b), (ba) or (c) of the definition of professional service in subsection 3(1); or
(b) a professional service (as defined in subsection 3(1)) that is constituted by assistance at an operation.

registered medical practitioner means a person:

(a) registered under the National Law in the medical profession; or
(b) registered or licensed as a medical practitioner under a law of a State or Territory that provided for the registration or licensing of medical practitioners (within the meaning of that law).

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Source text: opening excerpt

Sourced from the Federal Register of Legislation (legislation.gov.au), CC BY 4.0.

Part I Preliminary

Part I—Preliminary

1 Short title

This Act may be cited as the Health Insurance Act 1973.

2 Commencement

This Act shall come into operation on the day on which it receives the Royal Assent.

3 Interpretation

(1) In this Act, unless the contrary intention appears:

ABN has the meaning given by section 41 of the A New Tax System (Australian Business Number) Act 1999.

accredited pathology laboratory means premises in respect of which there is in force an approval under section 23DN.

accredited podiatrist means a podiatrist who is accredited by the Minister in writing under section 3AAA.

approved accreditor has the meaning given by paragraph 23DZZIAA(1)(b).

approved billing agent means a person or body in respect of whom an approval under section 20AB is in force.

approved form means a form approved by the Minister, by writing signed by him or her, for the purposes of the provision in which the expression occurs.

approved pathology authority means a person in respect of whom there is in force an undertaking given by the person, and accepted by the Minister, under section 23DF.

approved pathology practitioner means a person in respect of whom there is in force an undertaking given by the person, and accepted by the Minister, under section 23DC.

associate, of a person in relation to a professional service: see subsection 19AD(4).

Australia includes Norfolk Island, the Territory of Cocos (Keeling) Islands and the Territory of Christmas Island.

Australian resident means a person who resides in Australia and who is:

(a) an Australian citizen; or
(b) a person who is, within the meaning of the Migration Act 1958, the holder of a permanent visa; or
(ba) a person who has been granted, or who is included in, a return endorsement or a resident return visa in force under the Migration Act 1958; or
(c) a New Zealand citizen who is lawfully present in Australia; or
(d) a person (not being a person referred to in paragraph (a), (b), (ba) or (c)) who is lawfully present in Australia and whose continued presence in Australia is not subject to any limitation as to time imposed by law; or
(f) a person who:
(i) is, within the meaning of the Migration Act 1958, the holder of a temporary visa; and
(ia) is not covered by regulations made under subsection 6A(1); and
(ii) has applied for a permanent visa under that Act and the application has not been withdrawn or otherwise finally determined; and
(iii) has not, both:
(A) on or after the commencement of this paragraph, made an application for a protection visa under that Act (whether or not the person has applied for any other visa), other than an application that has been withdrawn or otherwise finally determined; and
(B) whether before or after the commencement of this paragraph, made an application for a parent visa under that Act (whether or not the person has applied for any other visa and whether or not the application for the parent visa has been withdrawn or otherwise finally determined); and
(iv) has not, whether before or after the commencement of this paragraph, made an application for a parent visa under that Act (whether or not the person has applied for any other visa), other than an application that has been withdrawn or otherwise finally determined; and
(v) in respect of whom either:
(A) another person, being the person’s spouse, parent or child (each having the same meaning as in the Migration Act 1958), is an Australian citizen or the holder of a permanent visa under that Act; or
(B) an authority to work in Australia is in force.