This Determination is the Health Insurance (Optometric services) Determination 2016.
3. Authority
This Determination is made under the Health Insurance Act 1973.
4. Definitions
(1) In this Determination:
Act means the Health Insurance Act 1973.
bulk-billed for a relevant service, means:
(a) a medicare benefit is payable to a person in relation to the service; and
(b) under an agreement entered into under section 20A of the Act:
(i) the person assigns, to the person by whom the service is provided, his or her right to the payment of the medicare benefit; and
(ii) the second-mentioned person accepts the assignment in full payment of his or her fee for the service provided.
care recipient means a person receiving residential care under section 21-2 of the Aged Care Act 1997.
old item 10900 means item 10900 of the general medical services table as in force at any time before the repeal of the item by Part 1 of Schedule 1 to the Health Insurance Legislation Amendment (Optometric Services and Other Measures) Regulation 2014.
relevant provisions means all provisions, of the Act and regulations made under the Act, and the National Health Act 1953 and regulations made under that Act, relating to medical services, professional services or items.
relevant service means a health service, as defined in subsection 3C(8) of the Act, that is specified in the Schedule.
residential aged care facility means a facility where residential care (within the meaning given by section 41-3 of the Aged Care Act 1997) is provided.
Schedule means the Schedule to this Determination.
telehealth eligible area has the same meaning as in the general medical services table.
Note: The following terms are defined in subsection 3(1) of the Act:
clinically relevant
general medical services table
optometrist
(2) In this Determination, Group A10 refers to the group of all the relevant services specified in items the Schedule, Subgroup 1 of Group A10 refers to the group of relevant services specified in items 10905 to 10944 of the Schedule and Subgroup 2 of Group A10 refers to the group of relevant services specified in items 10945 to 10948 of the Schedule.
(3) Unless the contrary intention appears, a reference in this Determination to a provision of the Act or the National Health Act 1953 or regulations made under the Act or under the National Health Act 1953 as applied, adopted or incorporated in relation to specifying a matter is a reference to those provisions as in force from time to time and any other reference to provisions of an Act or regulations is a reference to those provisions as in force from time to time.
Subdivision Part 1 - Health Insurance (Optometric services) Determination 2016 | Zoe
5. Treatment of relevant services
For subsection 3C(1) of the Act:
(a) a relevant service, other than the service described in item 10944, provided in accordance with this Determination and as a clinically relevant service, is to be treated, for the relevant provisions, as if:
(i) it were both a professional service and a medical service; and
(ii) there were an item in the general medical services table that:
(A) related to the service; and
(B) specified for the service a fee in relation to each State, being the fee specified in the Schedule in relation to the service.
(b) the relevant service described in item 10944, provided in accordance with this Determination and as a clinically relevant service, is to be treated, for the relevant provisions of the Act other than subsection 3(5), as if:
(i) it were both a professional service and a medical service; and
(ii) there were an item in the general medical services table that:
(A) related to the service; and
(B) specified for the service a fee in relation to each State, being the fee specified in the Schedule in relation to the service.
6. Application of item 10929
Item 10929 does not apply to a service if the patient’s requirement for contact lenses is only for any of the following reasons:
(a) because the patient does not want to wear spectacles for reasons of appearance;
(b) because the patient wants contact lenses for work or sporting purposes;
(c) because the patient has difficulty in using, or cannot use, spectacles for psychological reasons.
7. Application of items 10931, 10932 and 10933
If item 10931, 10932 or 10933 applies to a service, the fee mentioned in that item applies in addition to the fee mentioned in another item in Subgroup 1 of Group A10 that applies to the service.
8. Application of items 10940 and 10941
(1) For this section, the following are perimetry services:
(a) a service described in item 10940;
(b) a service described in item 10941.
(2) For a particular patient, a maximum of two perimetry services apply in a 12 month period.
9. Limitation on item 10943
Item 10943 does not apply to a service used to assess learning difficulties or learning disabilities.
10. Limitation on items
(1) Item 10943 may only apply to a service in respect of a particular patient once in a 12 month period.
(2) Item 10942 may only apply to a service in respect of a particular patient twice in a 12 month period.
(3) Items 10921 to 10929 may only apply to a service in respect of a particular patient once in a 36 month period.
11. Limitation on item 10944
Item 10944 does not apply to a service on the same occasion as a service mentioned in any of items 10905, 10907, 10910, 10911, 10912, 10913, 10914, 10915, 10916 and 10918.
12. Application of items 10945 and 10946
Items 10945 and 10946 do not apply to a service if the patient or specialist travels to a place in order for the patient to satisfy the requirement in subparagraph (c)(i) of the item that, at the time of the attendance, the patient is at least 15 kilometres by road from the specialist.
13. Application of items 10945 to 10948
Items 10945 to 10948 only apply to a service if the video conferencing consultation in which the patient is participating is a service for which there is an item in the general medical services table, or treated as being in the table because of subsection 3C(1) of the Act.
14. Professional attendance items and services provided with non-medicare services or autologous injections of blood or blood products
(1) Clause 1.2.5 of the general medical services table has effect as if items 10905 to 10929 were also specified in subclause 1.2.5(1).
(2) Clauses 1.2.8 and 1.2.9 of the general medical services table have effect as if items 10905 to 10948 were also specified in those clauses.