Heart health assessment: this is not defined independently in the Determination but is described by the service components in the Schedule. The service must include collection of relevant information including a patient history; a basic physical examination that must record blood pressure and cholesterol; initiating interventions and referrals as indicated; implementing a management plan; and providing the patient with preventative health care advice. The attendance must last at least 20 minutes and be provided at consulting rooms. The service is a professional attendance, not a health screening service as that term is defined in subsection 19(5) of the Act, though the Determination does not explicitly exclude the health screening service prohibition. The term “clinically relevant service” in section 6 refers to the definition in subsection 3(1) of the Act, which excludes a health screening service unless prescribed. By making this Determination, the Minister has effectively determined that the service is a clinically relevant service, which implies it is not a health screening service or has been prescribed as an exception. That is an important but unstated assumption.

Prescribed medical practitioner: defined by reference to clause 7.1.1 of the Health Insurance (General Medical Services Table) Regulations 2021. This provision defines a prescribed medical practitioner as a medical practitioner who is not a general practitioner, not a specialist, and not a consultant physician. It also excludes certain other categories. This means item 177 cannot be billed by a GP (who must use item 699) or by a specialist or consultant physician. It is available to hospital doctors, registrars, and other non-GP, non-specialist medical practitioners who meet the definition. This distinction matters for fee differential: item 177 pays $16 less than item 699 for the same service components.

Relevant service and relevant provisions: section 5 defines “relevant provisions” as all provisions of the Health Insurance Act and its regulations, and the National Health Act 1953 and its regulations, relating to medical services, professional services or items. This is broad and means the deemed items are treated as if they were part of the MBS for all purposes, including claiming, assignment of benefit, and compliance rules. “Relevant service” means a health service (as defined in subsection 3C(8) of the Act) specified in the Schedule.

Frequency limitation: section 7(3) creates a 12 month look-back rule. The prohibition applies not only to prior claims for item 699 or 177, but also to prior claims for any item in Group A14 (health assessments) except item 715, and any item in Group A7 Subgroup 5 (non-specialist practitioner health assessments) except item 228. Item 715 is the Aboriginal and Torres Strait Islander health assessment commonly known as “Health Check”. Item 228 is a non-specialist practitioner health assessment for people aged 40 to 74 who are at risk of type 2 diabetes or other chronic diseases. These exceptions mean that having had an Aboriginal health check or that specific diabetes risk assessment does not disqualify a patient from receiving the heart health assessment. But any other item in those groups (such as item 701, a comprehensive health assessment for people aged 75 and over) within the previous 12 months will disqualify the patient.

Indexation: section 8 provides for a single indexation event at 1 July 2025. The fee is multiplied by 1.024 (a 2.4 percent increase) and rounded to the nearest five cents. No further indexation is provided. This means the fees will be fixed after that date until the instrument is repealed, leading to real erosion from inflation.

This Determination directly affects general practitioners and prescribed medical practitioners who provide heart health assessments in consulting rooms. For GPs, item 699 offers a fee of $80.10 (to be indexed to approximately $82.00 in 2025). For prescribed medical practitioners, item 177 offers $64.10 (to be indexed to approximately $65.65 in 2025). These practitioners must ensure they meet the service components and the 12 month frequency limitation. The Determination also affects patients aged 30 years or older who may wish to receive a heart health assessment. They must not have had a disqualifying health assessment within the previous 12 months. The Determination indirectly affects practice managers and billing staff who must code correctly, check MBS history for prior assessments, and update fees after indexation. It also affects Medicare processing systems, which must recognise these deemed items and apply the correct rules from the General Medical Services Table as modified by section 7.

The Determination interacts with providers of competing MBS items. For example, a GP who would otherwise bill a comprehensive health assessment (item 701) for a patient aged 75 or over cannot also bill item 699 for the same patient in the same 12 month period (because item 701 is in Group A14 and is not excluded). This may cause some patients to choose between health assessments or receive them in different years. The Determination also affects the Department of Health and Aged Care, which must publish the indexed fees on MBS Online as stated in the note to section 8. The sunset clause affects anyone planning long-term care arrangements: after 30 June 2028, no Medicare rebate will be available for these assessments unless a new determination is made.

Private health insurers are not directly affected because the items are Medicare items, but they may be indirectly affected if the assessment leads to referrals for specialist services that attract private hospital or medical benefits.

Duties on practitioners: A practitioner who bills item 699 or 177 must provide all five components listed in the Schedule: collection of relevant information including patient history; a basic physical examination including recording blood pressure and cholesterol; initiating interventions and referrals as indicated; implementing a management plan; and providing the patient with preventative health care advice. The attendance must last at least 20 minutes. The practitioner must verify that the patient is aged 30 years or over and that the patient has not had a relevant previous service within the previous 12 months as per section 7(3). This requires checking the patient’s Medicare claim history or the patient’s own records. The practitioner must also ensure the service is provided at consulting rooms (defined in the broader MBS context as premises other than a hospital or residential aged care facility). There is no duty to bulk bill; the practitioner may choose to charge a gap fee, but the Medicare benefit is based on the scheduled fee.

Rights of practitioners: A practitioner who meets the conditions has a right to receive the Medicare benefit specified in the Schedule. The determination creates a statutory entitlement to that benefit for a clinically relevant service. Practitioners also have the right to rely on the indexation in section 8 from 1 July 2025, meaning the higher fee applies automatically.

Duties on patients: Patients have no express duties under this Determination, but they must not fraudulently claim the service or provide false information. If a patient has had a disqualifying health assessment, the practitioner should not bill the item; the patient may be asked to pay privately. Patients have the right to receive the service with the Medicare rebate if eligible.

Duties on the Commonwealth: The Commonwealth must pay the Medicare benefit for eligible claims, update the fee schedule at indexation, and ensure that the relevant provisions of the Act and regulations apply to these items as if they were in the general medical services table.

The Determination itself does not create penalties, but violations of its conditions can trigger penalties under the Health Insurance Act 1973. The most relevant provision is section 128A, which makes it an offence to make a false or misleading statement in connection with a Medicare claim. If a practitioner bills item 699 or 177 when the service does not meet the component requirements, the time requirement, the location requirement, or the frequency limitation, the claim is not for a clinically relevant service and may be considered false. The maximum penalty for an individual is 1,000 penalty units (currently $313,000) or imprisonment for 5 years, or both. Corporate penalties are higher. Additionally, the Commonwealth can recover overpayments under section 129AA of the Act, which allows recovery of benefits paid in respect of a service that was not a clinically relevant service or not properly rendered. The Professional Services Review scheme also applies: a practitioner who engages in inappropriate practice (such as excessive servicing or failing to meet clinical standards) can be investigated and may face reprimand, suspension, or disqualification from Medicare. The Determination’s requirements (e.g., the 20 minute minimum, the five components) are enforceable through the Professional Services Review as well, because they form part of the definition of the service.

There is an additional enforcement risk related to the health screening service prohibition. Section 19(2) of the Act prohibits Medicare benefits for a health screening service unless prescribed. If a court or tribunal were to find that the heart health assessment is a health screening service and that the Determination does not validly prescribe it as an exception, then all claims under items 699 and 177 could be invalid. This is a structural risk. However, the inclusion of intervention, management, and preventative advice argues against it being a pure screening service. The Determination likely assumes it is not a health screening service. The risk is low but should be noted.

For patients, there is no direct penalty for receiving the service inappropriately, but if the patient knowingly misleads the practitioner about prior assessments, the patient may be liable for an offence under section 129A (obtaining a financial advantage by deception). In practice, enforcement actions are directed at providers, not patients.

This Determination operates under subsection 3C(1) of the Health Insurance Act 1973, which empowers the Minister to determine that a specified health service is a clinically relevant service and to specify the fee for that service. Section 6 of the Determination deems the items to be part of the general medical services table for the purposes of “relevant provisions”, defined broadly in section 5 to include the Health Insurance Act and its regulations and the National Health Act 1953 and its regulations. This means the usual MBS rules about claiming, assignment, and limiting apply. For example, the Health Insurance (General Medical Services Table) Regulations 2021 contain rules about multiple services, such as the “90 day rule” or restrictions on claiming more than one item per attendance. These rules apply to items 699 and 177 as if they were in the table. Section 7 of the Determination specifically modifies two clauses of the General Medical Services Table Regulations: clauses 2.15.1 and 2.15.14. Clause 2.15.1 sets out when health assessment items cannot be claimed together. By deeming items 699 and 177 to be specified in that clause, the determination ensures that these items are subject to the same bundling restrictions as other health assessment items. Clause 2.15.14 deals with the frequency of health assessments, and the determination effectively inserts items 699 and 177 into that clause, reinforcing the 12 month limitation (though the determination already has its own frequency limitation in section 7(3)).

The Determination also interacts with the National Health Act 1953, particularly in relation to the Pharmaceutical Benefits Scheme. The management plan required in the service components may lead to prescriptions that are covered by the PBS. The PBS rules about continuing therapy and safety net thresholds apply independently.

The Privacy Act 1988 applies to the collection and handling of patient health information during the assessment. The determination does not provide any exemption from privacy obligations.

State and territory health practitioner regulation laws require practitioners to practice within their scope. Item 177 is limited to prescribed medical practitioners as defined in the General Medical Services Table Regulations. If a practitioner is not within that definition, they cannot use item 177 and must use another appropriate item or private billing.

Based on the instrument as provided, there is no evidence of any amendments to this Determination since its commencement. The original instrument is the Health Insurance (Section 3C General Medical Services - Heart Health Assessment No.2) Determination 2019. The “No.2” in the title suggests that there may have been a predecessor (No.1), but that is not part of this instrument and cannot be assumed. The repeal date of 30 June 2028 is set by section 3A, which indicates that the instrument has a fixed lifespan. There is no provision for automatic extension. If the Department wishes to continue the items beyond that date, a new determination must be made, possibly incorporating any changes. The indexation provision in section 8 only applies once in 2025, which could be seen as a de facto amendment through indexation (replacing the fee amount), but it is an automatic operation rather than a legislative amendment. Any other alteration to the service requirements or fees would require an amending instrument. Given the sunset, the instrument may not be amended further; instead, it may be replaced closer to the expiry date.

There is no reported litigation involving this specific Determination. As a relatively narrow section 3C determination with a limited lifespan and subject matter, it is unlikely to have been challenged in court. However, section 3C determinations generally have been considered in a few cases. For example, in Medical Benefits Fund of Australia Ltd v Cassidy (1989) 85 ALR 747, the High Court considered the scope of the Minister’s power under section 3C. That case involved a challenge to a determination that excluded certain services from Medicare risk equalisation arrangements. The court held that the Minister’s power under section 3C is broad but must be exercised for the purpose of the Act. This general principle would apply to this Determination: if a challenge were brought, a court would examine whether the heart health assessment is a health service, whether the determination is for a proper purpose, and whether the service is a clinically relevant service (not a health screening service). The risk of a successful challenge on health screening grounds exists but is speculative. There is no known judicial interpretation of the specific components required by items 699 and 177. Practitioners should assume that courts would give the service description its ordinary meaning and that any failure to include all components would result in the service not being a clinically relevant service for the purposes of the determination.

The 12 month look-back is broader than the item itself. Section 7(3)(b) disqualifies a patient who has had any service in Group A14 (health assessments) except item 715, or any service in Group A7 Subgroup 5 (non-specialist practitioner health assessments) except item 228, within the previous 12 months. This means a patient who had a comprehensive health assessment for the aged (item 701) or a health assessment for people with a chronic condition (item 707) cannot have the heart health assessment within 12 months. A practitioner cannot rely on the patient’s memory; they must check the Medicare claims history. This is a compliance trap for high volume practices.

The 20 minute minimum is a floor, not an average. If the consultation ends at 19 minutes, the item cannot be billed, even if all components were covered. Time must be documented. There is no higher fee for longer consultations; the same fee applies regardless of whether the consultation takes 20 minutes or 40 minutes.

The service must be at consulting rooms. The Schedule explicitly says “at consulting rooms”. If the assessment is done in a hospital outpatient clinic, a residential aged care facility (unless that facility qualifies as consulting rooms, which is unlikely), or the patient’s home, the item does not apply. The MBS definition of consulting rooms typically means a room or suite of rooms used exclusively for medical practice, not a hospital.

Item 177 is only for prescribed medical practitioners. This definition in clause 7.1.1 of the General Medical Services Table Regulations is restrictive: it excludes GPs, specialists, consultant physicians, and certain other categories. A hospital registrar may be a prescribed medical practitioner, but a visiting specialist cannot bill item 177. If a medical practitioner is not a prescribed medical practitioner, they cannot use item 177 and cannot use item 699 (which is for GPs only). They would have no MBS item for the heart health assessment and would need to private bill.

The indexation is a one-off event. After 1 July 2025, the fees are fixed. With inflation, the real value of the fee will decline each year until the instrument is repealed in 2028. The indexation formula (1.024 times the original fee) is also a single multiplier; if inflation exceeds 2.4% between the instrument’s commencement and 2025, the fee will have been eroded even before indexation.

The sunset is absolute. The instrument is repealed on 30 June 2028 at 11:59 pm. Any service provided after that time cannot be billed under items 699 or 177, even if the service was booked earlier. Practitioners must be aware of the expiry date and plan alternative billing approaches.

The service description uses “must include”. The five listed components are mandatory. If any is omitted, the service does not meet the item descriptor. For example, if blood pressure and cholesterol are not both recorded, the item is not payable. The requirement to “initiating interventions and referrals as indicated” may be satisfied even if none are clinically indicated, but the practitioner should document the clinical reasoning. However, if the practitioner does not initiate any intervention or referral and does not document why, the claim could be questioned.

Overlap with other health assessment items. If a GP provides a heart health assessment and then within 12 months provides a standard health assessment under item 701, the second assessment may be non-compliant because the heart health assessment is deemed to be in Group A14 for the purposes of clause 2.15.1 (via section 7). The restriction works both ways: having a heart health assessment prevents another group A14 health assessment within 12 months, and having another group A14 health assessment prevents the heart health assessment.

Practitioners should establish a standard workflow for heart health assessments under this Determination. The first step is patient eligibility screening. Before booking the appointment, check whether the patient is aged 30 years or over. Confirm that the patient has not received item 699 or 177 in the previous 12 months, and has not received any item in Group A14 (other than item 715) or any item in Group A7 Subgroup 5 (other than item 228) in that period. This can be done by asking the patient for a Medicare history or by using practice software that can pull MBS claim data. Document the check in the clinical record.

The consultation must last at least 20 minutes. Schedule a longer appointment to allow for all components. Use a timer or note the start and end times in the record. During the consultation, ensure the five components are covered: collect patient history (especially cardiovascular risk factors), perform a basic physical examination that includes recording blood pressure and blood cholesterol (either point-of-care or a lab referral), initiate any indicated interventions or referrals (e.g., prescription of statins, referral to a dietician), implement a management plan (which could be a written care plan, though not necessarily a GP Management Plan under item 721), and provide preventative health care advice (e.g., diet, exercise, smoking cessation). Document each component explicitly in the patient record. If cholesterol is not taken on the day (e.g., patient was fasting), it may still be acceptable if the cholesterol level is recorded from a recent test; the descriptor says “recording blood pressure and cholesterol”, not necessarily performing the test on the day. But it is safer to take it at the appointment.

The location must be consulting rooms. Ensure the practice address meets the MBS definition (not a hospital, not a nursing home). Use the correct item number: item 699 for a GP, item 177 for a prescribed medical practitioner (as defined). If the practitioner is not a GP and not a prescribed medical practitioner, they cannot bill either item; they must consider private billing.

After 1 July 2025, update the fee schedule in the practice software. The indexed fee for item 699 will be $80.10 × 1.024 = $82.0224, rounded to the nearest five cents → $82.00. For item 177 it will be $64.10 × 1.024 = $65.6384, rounded to $65.65. Use these new fees for claims from that date.

Before 30 June 2028, consider what will happen after the sunset. If the instrument is not renewed, practitioners will not be able to bill these items. They may need to use alternative MBS items for cardiovascular risk assessment (e.g., item 109, a standard GP attendance plus a separate health assessment item if eligible) or private billing. Monitor the Department of Health and Aged Care for a replacement instrument.

Maintain records for at least two years after the service (the usual Medicare retention period under section 129AA). Keep a note of the patient’s prior health assessment history to defend against compliance audits. If a patient has had a disqualifying prior service, do not attempt the heart health assessment under this Determination; instead, use a different item or bill privately.