Bills Digest no. 54 2015–16
PDF version [723KB]
WARNING: This Digest was prepared for debate. It reflects the legislation as introduced and does not canvass subsequent amendments. This Digest does not have any official legal status. Other sources should be consulted to determine the subsequent official status of the Bill.
Amanda Biggs and Alex Grove, Social Policy Section
Leah Ferris, Law and Bills Digest Section
24 November 2015
Contents
Purpose
of the Bill
Background
Committee consideration
Policy position of non-government parties/independents
Position of major interest groups
Financial implications
Statement of Compatibility with Human Rights
Key issues and provisions
Concluding comments
Date introduced: 21
October 2015
House: House of
Representatives
Portfolio: Health
Commencement: Sections
1 to 3 commence on Royal Assent. Schedule 1 commences on 1 January 2016.
Links: The links to the Bill,
its Explanatory Memorandum and second reading speech can be found on the
Bill’s home page, or through the Australian
Parliament website.
When Bills have been passed and have received Royal Assent, they
become Acts, which can be found at the ComLaw
website.
The Health Insurance Amendment (Safety Net) Bill 2015 amends
the Health Insurance Act 1973 (HIA)[1]
to replace the existing Medicare safety nets, which assist patients with gap
and out of pocket costs for out of hospital services, with a single Medicare safety
net.
Broadly, the Bill:
- inserts
new definitions in respect to eligibility for the Medicare safety net
- repeals
existing provisions around the operation of the Original Medicare Safety Net
(OMSN), the Extended Medicare Safety Net (EMSN) and the Greatest Permissible
Gap (GPG)
- inserts
provisions that specify the operation of a single Medicare safety net,
including new safety net thresholds and accumulation amounts and
- inserts
other provisions clarifying when and to whom Medicare benefits are payable, and
other minor amendments.
The Bill proposes to retain the 80 per cent safety net
benefit available under the existing EMSN, subject to a new cap (defined as 150
per cent of the schedule fee, minus the standard Medicare rebate). It proposes
lower expenditure thresholds than under the EMSN—$400 for concession card
holders, $700 for FTB(A) families and ‘confirmed’ singles,[2]
and $1000 for all other families and unconfirmed singles.[3]
The amount of out of pocket costs that will be allowed to accumulate toward the
safety net threshold will also be capped to 150 per cent of the Medicare fee,
minus the rebate.
In addition, the Bill proposes amendments that expand and
streamline benefit arrangements for families and add greater flexibility. For
example, it proposes to allow couples who live apart because of illness to
register as a family and pool their out of pocket expenses, which is not
currently allowed.[4]
Medicare benefits are available to help patients meet the
cost of clinically relevant medical and health services provided by registered
practitioners. If the practitioner chooses to bulk bill (by accepting the
Medicare benefit as full payment for the service) the service is free to the
patient. Nationally, around 77.9 per cent of all Medicare services are bulk
billed.[5]
The payment of benefits only applies to a professional
service listed in the Medicare Benefits Schedule (MBS). Generally the benefit
is set at 85 per cent of the schedule fee, except for the following:
-
for services provided by a general practitioner (GP) to
non-referred, non-admitted patients, or for services provided on behalf of a GP
by a practice nurse or Aboriginal and Torres Strait Islander health
practitioner, 100 per cent of the Schedule fee
-
for professional services to a patient as part of an episode of
hospital treatment (other than public patients), 75 per cent of the Schedule
fee and
-
75 per cent of the Schedule fee for professional services
rendered as part of a privately insured episode of hospital-substitute
treatment.[6]
Medicare helps fund many services, but patients may still be
liable for some of the cost. Medicare sets a minimum fee for a service (the
schedule fee) and the benefit amount (usually 85 per cent of the fee, also
called the rebate), but a medical practitioner is still free to set their own
fees.[7]
This means that patients can face high costs even after receiving a Medicare rebate.
Two concepts are used to describe the costs that patients
can incur when accessing Medicare services:
- ‘Gap
amount’. This refers to the difference between the MBS schedule fee and the
MBS benefit (rebate) that the patient receives and
- ‘Out
of pocket costs’. This refers to the difference between the MBS benefit and
the fee charged by the doctor. Out of pocket costs are made up of any gap
amount plus any fee that the doctor charges in excess of the MBS
schedule fee.[8]
Over the years, three measures have been introduced to help
ameliorate high costs for patients. The first two measures described below
relate to the gap amount, while the third relates to out of pocket costs.
Greatest Permissible Gap (GPG)
The Greatest Permissible Gap (GPG) has applied since
Medicare commenced in 1984. The GPG ensures the gap between the MBS fee and the
85 per cent benefit cannot exceed the prescribed GPG amount (which is indexed
annually to CPI). The GPG particularly helps ameliorate high out of pocket
costs associated with higher fee out of hospital services.[9]
If the gap between the schedule fee and the Medicare benefit would otherwise exceed
the GPG, the benefit is increased to ensure the gap payment is equal to the GPG
amount. For example, if the schedule fee for a service is set at $800, the benefit
is normally 85 per cent of this, or $680, leaving a $120 gap for the patient.
The GPG is currently set at $79.50 (it was indexed on 1 November 2015) so the benefit
for the service increases to $720.50, meaning the patient only has to pay a $79.50
gap.[10]
Original Medicare Safety Net (OMSN)
The Medicare Safety Net was introduced in 1991. Originally
it was intended to help offset the cost of a newly introduced $2.50 patient
co-payment, which was later withdrawn, while the safety net was retained.[11]
The Original Medicare Safety Net (OMSN), as it is now called, reimburses patients
when they incur gap expenses for out of hospital services above a set threshold.
As noted, gap expenses are defined as the difference between the Medicare benefit
(usually 85 per cent of the schedule fee) and the Medicare schedule fee. Once
gap expenses exceed the prescribed threshold patients receive 100 per cent
reimbursement of the schedule fee for the remainder of the calendar year for
out of hospital services. The current annual threshold is set at $440.80.[12]
OMSN only applies to gap expenses incurred by individuals (not families).
Extended Medicare Safety Net (EMSN)
In 2004, the safety net was expanded to provide additional
benefits and extended to cover expenses incurred by families. The Extended
Medicare Safety Net (EMSN) operates so that once cumulative out of pocket expenditure
on out of hospital services exceeds an annual threshold, the Medicare benefit
increases to cover either 80 per cent of further out of pocket costs or the
EMSN benefit cap for the remainder of the calendar year (whichever is lower). The
EMSN benefit cap is generally set at 300 per cent of the MBS fee (that is three
times the fee) up to a maximum of $500.[13]
The EMSN is paid in addition to the OMSN and the Medicare benefit. Medicare benefit
caps are recorded automatically through Medicare Australia’s claiming systems
and are applied at the time of processing the claim for payment.[14]
Caps on EMSN benefits were introduced following the findings
of a 2009 independent review of the EMSN.[15]
This review found that EMSN expenditure was growing at a faster rate than
Medicare spending and had contributed to a significant increase in average
provider fees, particularly in some specialities. It also found that most EMSN
benefits were distributed to the most socio-economically advantaged, and were
not providing assistance to those who were most disadvantaged. Initially caps
on EMSN benefits were introduced for selected out of hospital MBS items
identified as having excessive average fees (obstetrics, pregnancy related
ultrasounds, cataract surgery, hair transplantation, and a varicose vein
procedure). Following a second review of the EMSN in 2011, caps were introduced
for most out of hospital services.[16]
Two further measures have attempted to address safety net
expenditure: the lifting of the general EMSN threshold from $1,248.70 to $2,000
as of January 2015, and pausing indexation of the thresholds.[17]
Issues with the current safety net
arrangements
In introducing this Bill, Minister Ley argues that the
existing safety nets are unnecessarily complex, making it difficult for
patients and providers to understand their entitlements. While the capping
arrangements introduced in 2009 slowed the rate of growth in safety net
expenditure by 42 per cent,[18]
the Minister remains concerned that safety net expenditure remains too high.
Last year Medicare safety net expenditure totalled $414 million, significantly higher
than the $206 million forecast.[19]
As a proportion of Medicare expenditure (just over $20.3 billion in 2014–15), Medicare
safety net expenditure represents around 2 per cent.[20]
According to the Minister, some medical providers continue
to charge excessive fees, and current safety net arrangements may be
encouraging less safe practices as providers undertake more complex procedures
out of hospital in order to take advantage of the EMSN.[21]
The provisions in this Bill, she argues, will ‘restrict
excessive fee inflation by medical providers and hopefully encourage current
billing practices by some health providers to become more proportionate to
Medicare fees’.[22]
Calls for safety net arrangements to be simplified have been
made previously, notably by the independent National Health and Hospitals
Reform Commission (NHHRC) which considered the issue of safety nets in its 2009
report. The NHHRC argued:
[T]here are currently multiple safety nets and a patchwork of
government programs that partially meet the costs of some services. We need a
simpler, more family-centred approach that improves the affordability of health
care. [23]
Subsequently, the NHHRC recommended a review of safety net
arrangements, with a view to replacing the existing arrangements with a simpler,
more family-centred, approach.[24]
There is evidence that some medical providers continue to
charge excessive fees, particularly some medical specialists, where competitive
pressures are less potent. According to Dr Michael Grigg, President of the Royal
Australasian College of Surgeons, ‘some surgeons charge 10 times the fee
recommended by the Australian Medical Association’.[25]
The rate of bulk billing among specialists is among the lowest of all medical
providers—around 29.9 per cent. For anaesthetists the bulk-billing rate is 9.2
per cent.[26]
This means that patients can face high out of pocket costs for these services.
There is evidence that patient out of pocket costs for some specialist services
continue to rise at a relatively high rate. For example, the average out of
pocket payment for obstetrics was $247.80 in June 2015, up from $229.30 on the
previous year. In June 2010, the average out of pocket payment for obstetrics
was $176.90.[27]
Overall, this represents a 40 per cent increase in out of pocket costs over 5
years.
Still, there remains uncertainty as to the impacts of
recent efforts designed to curb safety net expenditure, such as capping, and increasing
the general EMSN threshold to $2000. It is not clear, for example, if the
distribution of safety net benefits continues to flow to the most advantaged in
our community, although the Department of Health has recently given evidence
that the MBS safety net is ‘typically engaged by people of middle income and
higher’.[28]
Nor is it clear the extent to which medical providers may be moving towards
less safe practices, as claimed by the Minister. Unlike previous policy
developments, the proposals in this Bill are not drawing on evidence from
independent reviews of safety net arrangements.
Meanwhile, a major review of the Medicare Benefits Schedule
(MBS) announced by Minister Ley in April this year is underway.[29]
A Taskforce has been established to ‘consider how services can be aligned with
contemporary clinical evidence and improve health outcomes for patients’.[30]
An interim report is due at the end of 2015.[31]
Given the potential for the Taskforce to make potentially major recommendations
around the operation of Medicare, it might be prudent for the provisions in
this Bill to be considered in the context of this interim report.
The enactment of this Bill is forecast to generate savings
of $266.7 million over five years.[32]
Savings are due to be re-directed to the Medical Research Future Fund (MRFF)
which was established earlier this year.[33]
The measure was originally announced as part of the
2014–15 Budget.[34]
Community Affairs Legislation
Committee
The Bill has been referred to the Community Affairs
Legislation Committee for inquiry and report by 23 November 2015.[35]
Details about the inquiry are available on the Committee’s
website.[36]
A public hearing was held on 16 November and the transcript is available on the
Committee’s website. On 23 November 2015 the Committee tabled its report.[37]
The majority of the Committee, while supporting the passage of the Bill, also
recommended that the Department amend the Explanatory Memorandum to ‘explain
the data and modelling underpinning the Bill’ and that the Bill be amended ‘to
include a review of the operation and outcomes of the new Medicare Safety Net
no later than 1 January 2021’. [38]
Senate Standing Committee for the
Scrutiny of Bills
The Senate Standing Committee for the Scrutiny of Bills had
no comment to make on the Bill.[39]
Australian Labor Party
In an initial response to the 2014–15 Budget, the Opposition
spokesperson on health, Catherine King described the proposed changes as making
the Medicare safety net ‘less fair’.[40]
Later she argued that the cost of many high fee services, such as PET scans for
cancer patients, would become unaffordable for many under the new arrangements.[41]
More recently, she described how the changes would ‘slug cancer patients,
families seeking IVF and those with chronic health conditions with even higher
out of pocket costs’.[42]
When the Bill was introduced for debate, Ms King indicated
that Labor would carefully consider the legislation, but that it still had
concerns about the impact of the changes on patients with ‘serious and costly
medical issues’.[43]
Subsequently, Ms King announced that Labor will not be
supporting the legislation in its current form.[44]
Australian Greens
No specific commentary from the Australian Greens on the
measures proposed in this Bill had been identified at the time of writing this
digest. However, the Greens have previously expressed concerns about growing
out of pocket costs to patients. In August 2013, Greens Senator Richard Di
Natale moved to hold a committee of inquiry into high out of pocket patient
costs.[45]
More recently, Senator Di Natale reported on the outcomes of the subsequent
Senate inquiry. He noted that the inquiry had found discrepancies and problems
in the operation of the two main safety nets, the Medicare safety net and the
Pharmaceutical Benefits Scheme safety net, and called for reform:
We learnt that one of the big problems is that they do not
provide people with the upfront assistance they need. People who do not have
the disposable income to be able to afford large out-of-pocket costs do not get
the benefit from the safety nets that they need. In fact, some people will
achieve the threshold for one safety net but not benefit from the other safety
net. One of the clear recommendations was that we need a single safety net for
out-of-pocket healthcare expenses that covers medical services, medicines and
other healthcare expenditure. A recommendation to government was that they
implement such a significant reform.[46]
Other non-government parties and
independents
Independent Senator Nick Xenophon has indicated that he
will not vote for the Bill, citing concerns about higher costs for patients
accessing in vitro fertilisation (IVF) treatment.[47]
Commentary from other non-government parties and
independents was not identified at the time of writing this Digest.
Commentary on this measure at the time of the Budget was
not extensive; the main focus for many stakeholders was instead on the proposed
patient co-payment (which was subsequently dropped).
The proposed safety net changes were discussed briefly at
Budget Estimates in June 2014. As explained by
Dr Bartlett, from the Department of Health, savings would be achieved because
the 150 per cent cap on benefits will limit the amount of benefits paid to some
patients:
The save comes because there are certain areas where there
are very high fees charged, and the 150 per cent of the scheduled fee cap means
that those will no longer be covered in the same way. But what happens through
this is that a significant number of extra people get access to the safety net,
and so more people will be getting covered by the safety net—but a number will
get covered for a significantly smaller amount.[48]
Patient out of pocket costs
The latest data from the Australian Institute of Health
and Welfare (AIHW) indicates that Australian patients continue to incur high
out of pocket costs for their health care. In 2013–14, individuals spent an
estimated $27.7 billion out of their own pockets on health goods and services.[49]
Out of pocket expenditure by individuals has grown at a faster rate than
overall government expenditure on health. Over the decade, it grew by an
average of 6.2 per cent a year in real terms compared with 5.3 per cent for all
non-government sources.
Patient out of pocket costs have also been affected by a
number of recent savings measures. In the 2013–14 Budget, the Labor government
announced the phase-out of the Net Medical Expenses Tax Offset.[50]
It also announced an increase in the general threshold for the EMSN, from
$1221.90 to $2000 from January 2015.[51]
In the 2014–15 Budget the Coalition announced that annual indexation of
Medicare fees would be paused for two years, which was then extended to 2018.[52]
The pause in indexation has an effect on the incomes of medical practitioners
who bulk bill, as they accept the Medicare benefit as full payment for the
service. If practice costs increase, fewer practitioners may opt to bulk bill,
meaning patients may face higher out of pocket costs.
A number of commentators have argued that some patients will
face higher out of pocket costs as a result of this measure. Health expert
Anne-marie Boxall, writing for The Conversation noted that while some patients
will qualify for the safety net after spending less money, ‘they will have to
pay more of the high out of pocket costs than they do now.’ For those services
‘well in excess of the Medicare schedule fee’ the new safety net ‘will not
provide protection for costs’. She has described this as a ‘new, simpler
Medicare safety net ... but with holes.’[53]
Another health commentator Jennifer Doggett described the
proposed lowering of the safety net thresholds as ‘woefully inadequate to
support the increased numbers of people who will have difficulty meeting their
health care expenses’.[54]
Concerns have been raised over how the safety net changes
could adversely affect certain categories of patients, such as cancer patients.
Under the new safety net, cancer patients undergoing expensive radiotherapy
treatment may face higher out of pocket costs due to the imposition of the 150
per cent cap on benefits, according to one cancer expert:
Private patients undergoing a typical six to seven-week
course of radiation treatment have $12,000 in out-of-pocket expenses but
$10,000 of this is covered by the Medicare safety net, Dr Guiney said. When the
150 per cent fee cap is introduced in January the Medicare safety net will
cover only $8000 of these bills leaving the patient $4000 out of pocket.[55]
There is also a concern that some patients who are only
charged the schedule fee might lose benefits under the OMSN changes:
Patients charged the Medicare schedule fee currently have
their out-of-pocket expenses capped at $440 a year, but this cap will be
removed under the Budget changes. These patients will now have to spend $1000
on out-of pocket expenses before qualifying for the safety net and getting back
80 per cent of any costs over this amount.[56]
The Australian Diagnostic Imaging Association (ADIA)
raised concerns about the proposed removal of GPG arrangements. The ADIA argue
that because many imaging services are higher cost, the GPG acts as an
important safety net because it limits patients’ liability for gap payments.
Removal of the GPG, they warn, will result in some patients facing higher gap
payments.[57]
Others argued this measure would add to demand for public
hospital services and increase waiting times.[58]
A number of commentators also pointed out that current
safety net arrangements do not assist in helping with the out of pocket costs
associated with health services such as dental care and medical aids and
appliances.[59]
This gap in coverage will continue under the proposed changes.
Concerns over patient costs remain of high potency. On the
introduction of the Bill, the AMA President Brian Owler said that the AMA opposes
the changes and that ‘the sickest and most disadvantaged Australians will be
hit hardest’.[60]
Royal Australian College of General Practitioners (RACGP)
President Dr Frank R Jones expressed concern that the 150 per cent cap on safety
net benefits, when coupled with the existing freeze on schedule fees, would
increase costs for vulnerable groups.[61]
Psychiatrists have also expressed concerns about this
Bill. Vice President of the National Association of Practising Psychiatrists
(NAPP), Dr Gil Anaf, argues that patients who require intensive psychiatric
treatment (that is who need to see a psychiatrist more than once a week) will
be disadvantaged. He says that patients who exhaust the number of sessions
currently allowed under one Medicare item number, and then move to an
alternative Medicare service, will be faced with higher out of pocket costs.[62]
The Department of Health has responded to questions about
increased out of pocket costs by stating that they expect some clinicians to
change their billing behaviour in response to the new arrangements, making it ‘a
little harder to predict specific outcomes for specific patients’.[63]
However, using the example of radiation oncology patients, they expect that:
There will be a number that become eligible for the first
time. There will be a number that are paying a little higher out-of-pockets. We
do not expect that there will be people who are currently eligible who will no
longer be.[64]
In recent evidence to the Senate Community Affairs
Legislation Committee inquiry into the Bill, the Department further advised
that it expects 53,000 additional people will qualify for the safety net due to
the lower income thresholds.[65]
Complexity
Despite the government’s intention to simplify safety net
arrangements, some commentators still point to its complexity.
In a Senate hearing after the budget announcement in May
2014, Adam Stankevicius from the Consumer’s Health Forum commented about how
the proposed changes, along with other recent changes, add to the complexity:
So it does go back down again, but again there are exclusions
and carve-outs for the proposed new safety net. This one is proposed to come in
on 1 January 2015. The one announced in the 2014–15 budget would come in on 1
January 2016 and bring it back down to $1,000. The carve-outs and the
exclusions get more technical and more difficult to work through. The capping
also gets more difficult to work through. It is not a simple matter of being
just as easy as it is now to reach the threshold. With a new lower threshold,
it will still be more difficult. Consumer confusion is one of the questions
when you start carving stuff out, excluding it, putting caps on it and only
having certain percentages that apply. You cannot necessarily plan your
healthcare expenditure to get to the threshold, particularly if you are making
decisions across financial years and you want to be able to ensure that you do
get some kind of compensation. As I said, if you have got a chronic illness and
you are trying to manage that across the years, it makes it more difficult.[66]
In an opinion piece in the Medical Journal of Australia,
three health experts argued that while the proposed safety net changes would
‘provide some relief to heavy users’, the measure ‘remains confusing and
further complicated by caps on particular medical fees’.[67]
Family arrangements
Stakeholder commentary has tended to concentrate on the issue
of costs for patients.
However, the RACGP has welcomed the broadened definition of
a family for safety net purposes as ‘a positive step towards recognising
complex family arrangements’.[68]
The Explanatory Memorandum (EM) notes that savings of
$266.7 million over five years are forecast. This is exactly as the forecast in
the 2014–15 Budget. Although not included in the EM the yearly breakdown of
forecast savings was provided in the budget papers:
Table 1: Simplifying Medicare safety net arrangements
Source: Budget 2014–15[69]
This chart shows that the bulk of the forecast savings are
expected to accrue in later years, once the new arrangements are fully
implemented. Some expenses are also forecast, most likely reflecting costs
associated with implementing the new arrangements. Savings beyond the forward
estimates are likely to accrue given the on-going nature of the Medicare
program.
It is not clear how other recent measures may interact with
this measure. In the 2014–15 Budget, annual indexation of most Medicare schedule
fees was paused for two years (general practice was initially exempt from the
pause).[70]
At the Mid Year Economic and Fiscal Outlook (MYEFO), the pause in indexation
was extended to July 2018 and GP fees were included in the pause.[71]
This prolonged pause in indexation raised concerns that it
would place a financial strain on general practice and force doctors to pass on
costs to patients, increasing their out of pocket costs.[72]
If the indexation pause results in significant increases to out of pocket costs
incurred by patients, it might be expected to have an impact on the forecast
savings. However, the forecast savings for the proposed new safety net have not
altered since the measure was first announced in the 2014–15 Budget, despite
subsequent lengthening of the indexation pause. This could indicate that the
government simply rejects assertions that patients will face higher out of
pocket costs as a result of the extended indexation pause. The Department of
Health has recently given evidence that bulk-billing rates have continued to
rise under the indexation pause, but that there has been a small increase of
about one dollar (3.6 per cent) in the patient contribution per GP service for
patients who are not bulk-billed.[73]
Another possibility is that the effects of a prolonged indexation pause on out
of pocket costs may not have been considered.
As required under Part 3 of the Human Rights (Parliamentary
Scrutiny) Act 2011 (Cth), the Government has assessed the Bill’s
compatibility with the human rights and freedoms recognised or declared in the
international instruments listed in section 3 of that Act. The Government
considers that the Bill is compatible as it does not raise any human rights
issues.[74]
The Statement of Compatibility prepared by the Department
correctly identifies that the Bill engages with the right to health and the
right to social security. While Article 12(1) of the International Covenant of
Economics, Social and Cultural Rights (ICESCR) defines the right to health as ‘the
right of everyone to the enjoyment of the highest attainable standard of
physical and mental health’,[75]
this does not translate to a right to be healthy.[76]
Rather it is a right to not only have access to adequate health care but also
to ‘safe and potable water and adequate sanitation, an adequate supply of safe
food, nutrition and housing, healthy occupational and environmental conditions,
and access to health-related education and information, including on sexual and
reproductive health’.[77]
While taking into account a State’s available resources, Article 12(1) places
an obligation on States to ‘adopt appropriate legislative, administrative,
budgetary, judicial, promotional and other measures towards the full
realization of the right to health’.[78]
Article 9 of the ICESCR provides that everyone has the
right to access social security.[79]
This ‘encompasses the right to access and maintain benefits, whether in cash or
in kind, without discrimination in order to secure protection, inter alia, from
... unaffordable access to health care’.[80]
Under Article 9, ‘all persons should be covered by the social security system,
especially individuals belonging to the most disadvantaged and marginalized
groups’, and ‘qualifying conditions for benefits must be reasonable,
proportionate and transparent’.[81]
The Government argues that while the Bill may increase the
out-of-pocket costs for some patients, overall more patients will now benefit,
particularly those who are financially disadvantaged:
While the average benefit under the new Medicare safety net
will reduce, the number of people who will receive a safety net benefit will
increase compared to the number of people who will receive a benefit under the
EMSN in 2015. It is anticipated that benefits under the new Medicare safety net
will be more equitably distributed between socio-economically advantaged and
disadvantaged areas. Currently, the EMSN disproportionately directs benefits to
people living in more advantaged areas and encourages fee inflation. This fee
inflation disadvantages people who do not qualify for safety net benefits.[82]
Parliamentary Joint Committee on
Human Rights
The Parliamentary Joint Committee on Human Rights questioned
whether the changes to the safety net are a justifiable limitation on the right
to social security and the right to health.[83]
While the Committee recognised that the Government’s rationale for reforming
the safety-net arrangements was considered to be a legitimate objective, it
noted that the changes might still not be justified where they
disproportionality affected vulnerable groups.[84]
The Committee noted that the proposed amendments will mean that a person will
be required to incur more out-of-pocket expenses before reaching the safety net
threshold (regardless of whether they are financially disadvantaged) and that
the removal of the Greatest Permissible Gap may also have a substantial impact
on vulnerable groups.[85]
The Committee found that the statement of compatibility did not adequately
justify the need for the amendments:
The statement of compatibility states that the Bill will mean
that the benefits of the safety net will be more equally distributed between
socio-economically advantaged and disadvantaged areas. However it does not
explain whether the Bill will result in many financially disadvantaged people
being worse off as a result of the changes. If this is the case, it is also
unclear what safeguards there are to ensure that financially disadvantaged
people are not effectively barred from accessing appropriate out-of-hospital
healthcare due to a reduction in the benefits payable to them.[86]
This section deals with notable or significant provisions.
For all other provisions the reader is advised to consult the EM which
adequately explains these proposed changes.
Schedule 1—Amendments to the Health
Insurance Act 1973
New definitions
Item 1 proposes new subsection 3(1) which
inserts new definitions for key terms, including the meanings of those used to
describe who is eligible for safety net benefits and new safety-net terminology.
Item 2 repeals sections 8 and 8A which specify the
current definitions relevant to the safety net, and inserts a new simplified
outline at 8AA.
Repeal of EMSN, OMSN and GPG and establishment
of new Medicare safety net
Items 6 and 7 repeal the existing provisions around
the safety net arrangements and propose the new Medicare Safety Net.
Item 6 repeals subsections 10(3) and 10(5) which
specify the GPG.
Item 7 repeals sections 10AA to 10C which specify the
operation of the OMSN and the EMSN. Item 7 replaces these sections with proposed
Division 3 which specifies the new safety net arrangements.
The new provisions include a simplified outline (proposed
subsection 10A) which broadly explains the new safety net in simple
language.
Proposed section 10B sets out the ‘general rule’ for
the Medicare safety net: the Medicare benefit paid to a person for a safety-net
service (defined below) will be increased by the safety net amount (defined in proposed
section 10R) once they have reached their safety net threshold for the
year. That is, people will receive a higher Medicare benefit to cover some of
their out of pocket costs once they have reached their threshold. This rule is
similar to the current EMSN arrangements.[87]
Proposed subsections 10BA(1) and (2) define a safety net
service, and specify that an episode of hospital treatment or hospital
substitute treatment cannot be a safety net service. This is the same as the current
arrangement which excludes hospital services from the Medicare safety net. Proposed
subsection 10BA(3) allows for the regulations to prescribe instances where
more than one professional service is taken to be a single safety net service.[88]
Proposed 10BA(4) specifies that if such regulations are made, these
regulations can also specify the schedule fee for these services, the method
for calculating the fee, the medical expenses to count for these services and
the method by which they are to be calculated. In such instances, proposed
subsection 10BA(5) specifies that the original individual services are not
considered a safety net service. This will replace current provisions in the HIA
which allow for the treatment of multiple services to be specified under the
HIA and classify these as ‘deemed services’.[89]
Proposed subdivision D sets out the framework for the
new safety-net thresholds and specifies the amounts at which they will apply to
different categories of people.
Proposed section 10D defines safety net expenses as the
sum of all qualifying or ‘relevant’ expenses for professional services
including the current service, incurred in a calendar year. To qualify for a
safety net benefit, these expenses must equal or exceed the safety net
threshold in a given calendar year.
Proposed section 10DB specifies how to determine an
out of pocket expense by using a simple formula: the total amount (expense)
of the medical service minus the Medicare benefit (or rebate).
Proposed section 10DC specifies a table which defines
the rate of the safety net threshold for different classes of persons (as
indexed under proposed section 10S). Rather than having two sets of out
of pocket expenditure thresholds—one for the OMSN and one for the EMSN—this proposes
a single set of thresholds. For a concessional person the safety net threshold
is set at $400; for an FTB(A) person or a person confirmed as a member of an
FTB(A) family, and for a confirmed single, the threshold is $700; for an
unconfirmed single and a person confirmed as a family other than FTB(A), the threshold
is $1000.[90]
As noted, these threshold levels are lower than the current EMSN thresholds.
The EMSN thresholds are currently $638.40 for concession cardholders and people
who receive FTB(A), and $2,000 for all other singles and families.[91]
Around 773,000 people are receiving safety net benefits in
2015. Under the proposed new arrangements, the Department of Health expects the
total number of those receiving benefits ‘to go up by over 50,000, with a
greater distribution towards the concessional.’[92]
Proposed subdivisions E, F, G, H and J deal with the
eligibility of families in different circumstances and family registration.
Registering a family
Currently section 10AA of the HIA sets out the
requirements for registering a family for the purposes of qualifying for the
safety net. Subsection 10AA(1) clarifies that a person’s spouse or any of their
dependent children are considered to be family members for the purposes of the
safety net. A spouse is defined broadly as either someone who is legally
married or someone in a de facto relationship. The definition excludes spouses
who are living apart on a permanent basis.
A dependent child is defined as a child under 16 who is
either in, or substantially in, the custody, care and control of the person, or
a person between the age of 16-25 who is receiving full time education at a
school, college or university and who is wholly or substantially dependent on
the person. Subsections 10AA(2)-(5) provide that a family member can apply at
any time to the Chief Executive Medicare (CEM) to have their family registered,
or to add the new family member, or to delete a family member and the CEM must
either register or vary the registration accordingly. A child, or a dependent
child, constitute the only exception to the rule that a person may not be
registered as a member of more than one family.[93]
The Bill proposes to replace section 10AA of the HIA
with proposed Subdivision E—Registering a Family. Proposed
section 10EA widens the scope of who is considered to be a spouse or a
dependent child for the purposes of determining the family safety net. Proposed
subsections 10EA (3) and (4) redefines the definition of spouse to
include married couples and de-facto partners who are not living together
because of a temporary absence from each other or because one or both of them
suffers from illness or infirmity. The Explanatory Memorandum points out this
will ensure that couples who are living in a nursing home or care facility will
still be able to be recognised as a family for the purpose of the safety net. This
amendment would serve to bring consistency in Commonwealth laws, because
currently subsection 2F(4) of the Acts
Interpretation Act 1901 contains the same arrangement—a de-facto couple
will still be considered to be together on a genuine domestic basis when they
are not living together because of a temporary absence from each other or
because one or both of them suffers from illness or infirmity.[94]
Proposed subsection 10EA(7) amends the definition of ‘dependent
child’ to include children who cannot study full-time due to illness or
infirmity.
Therefore, the Bill provides that a dependent child of a
person will now be defined as:
- a
child under 16 who is either in or substantially in the custody, care and
control of the person or
- a
person between the age of 16-25 who is receiving full time education at a
school, college or university (or who would be if not for illness or
infirmity), and who is wholly or substantially dependent on the person.
Proposed subsection 10EA(8) allows for the
regulations to prescribe additional definitions of a dependent child.
Proposed subsections 10E and 10EB inserts
similar provisions to those contained in section 10AA in relation to
registering a family or varying the registration to add a new family member or
delete a family member. However, proposed subsection 10EB(4), in
conjunction with proposed sections 10ED, provides that the CEM is not
obligated to register a family, or vary a family’s registration, where he is
not satisfied that either the new member has become a member of the family, or
the former member is no longer a member of the family, and is not allowed to
either register a family or vary a family’s registration where it would result
in the family being comprised of more than two spouses. Proposed section
10EC introduces new provisions to clarify the registration process for
where the new member of the family is a newborn. In particular, proposed subsection
10EC(3) places an additional burden on the CEM to ensure that where a
newborn child is a member of a family either applying for registration or to
vary their registration, the CEM must take such steps as are reasonable in all
the circumstances to ascertain the membership of the family. The Explanatory Memorandum provides no guidance as to the
rationale for this amendment.
Confirming the membership of a
family
Under current section 10AE of the HIA, if the CEM is
satisfied that a registered family is close to reaching a Medicare
Safety Net threshold, he/she must request that the registered family provide
confirmation to the Department of the names of people who were considered to
comprise the registered family for that year. This obligation applies even
where the registered family has not applied during the year to change its
composition. According to the Department, the confirmation process allows for
the Department to check the registered family’s eligibility for higher Medicare
benefits.[95]
If the registered family fails to provide confirmation, each family member will
not receive the increased benefits for that year.
New Subdivision F updates the process for providing
confirmation. Proposed section 10F allows for any member of a registered
family to provide confirmation by notifying the CEM, regardless of whether the CEM
has requested that they do so. However, under proposed subsections 10FA(1) and
(2) the CEM must still request that a registered family provide
confirmation where he/she reasonably believes that a member of the family may
in the near future be eligible for a safety net benefit amount (see below
regarding proposed subdivision R). Proposed subsections 10FA(4)-(6)
provide for time limits in which a member of the registered family can confirm
the composition of the family.
Consequences of changing the
registration of a family after the safety-net threshold is reached
Currently section 10AB of the HIA provides for the
scenario where a registered family member or members has reached their safety
net threshold and the composition of the registered family changes. Subsection
10AB(1) provides that where a family’s registration is varied due to the
addition of a new member, claims in respect of his or her medical expenses,
incurred during the calendar year in which the registration is varied but
before the variation, can be taken into account for the purpose of the safety
net and the extended safety net. However, 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 a benefit has
already been paid. Subsection 10AB(2) provides that where a family’s
registration is varied due to a person ceasing to be a member and one of the
family members (including the person ceasing to be a member) has not, at the
time of the variation, become entitled to increased benefits in respect of
medical expenses incurred in the calendar year in which the variation is made,
claims involving the person’s medical expenses will no longer be relevant with
respect to that family’s safety net. These claims will now apply to the
person’s own safety net (as an individual) or another family’s safety net
(where the person has registered with another family). Subsection 10AB(3)
provides for when family members have become entitled to increased benefits in
respect of medical expenses incurred in the calendar year and a person ceases
to be a family member (and the family membership is varied). In these
circumstances, claims involving the person’s medical expenses will continue to
be relevant with respect to the original family’s safety net and the person
will not be entitled to be treated as a member of another registered family
during the year.
New subdivisions G and J set out the
provisions relating to changes in the composition of families, including new
rules with respect to former spouses and former dependent children. Proposed
section 10G provides that where a person has reached the safety-net
threshold any changes to the composition of the registered family the person is
part of will not impact the person’s right to continue to receive safety-net
benefits for relevant services for the remainder of the calendar year. This
also applies where a person has reached the safety-net threshold and ceases to
be a member of a registered family. Proposed section 10GA introduces new
provisions which prevent a person who has reached their safety net threshold and
leaves their current family from forming a new family for the purposes of the
safety net. Specifically, where one person has reached their safety net
threshold (which allows other members of the family to reach their safety net,
including their spouse, and where costs may have been incurred by everyone in
the family) and then ceases to be a part of that family, the person will be
restricted from forming a registered family with anyone except their previous
spouse and dependent children. The Explanatory Memorandum states that these
restrictions ‘preserve the financial integrity of the safety net’ by not
allowing a person to help someone else reach the safety net where the costs may
have been incurred by their former spouse.[96]
Proposed section 10GB introduces similar provisions with respect to a
dependent child who has reached their safety net threshold and then ceased to
be a member of a registered family. In this case a former dependent child will
only be allowed to become a dependent child of another family or form their own
family with their dependent children. They will also be prohibited from
registering a spouse.
New subdivision J inserts similar provisions to those
contained in subsection 10AB(1) and provides that where a family membership has
been varied to include a new family member, increased benefits are not payable
in respect of which benefits have already been paid.
Where children are registered in more than one family
Currently subsection 10AC(3) provides for a simple solution
for where a child has been registered as a member of two families and a medical
expense has been incurred on the child’s behalf. Where the CEM is satisfied
that the expense was incurred by a particular adult, the expense will be
incurred for the purpose of the safety net in respect to the family the adult
is registered as a member of. However, where the CEM is not satisfied as to the
adult who incurred the expense, half of the expense will be incurred with
respect to one family and the other half in respect to the second family.
Proposed section 10H provides that the provisions
contained in new Subdivision H apply where a child has either been
registered as a member of two families for that calendar year or the person
ceases to be a dependent child of one family and becomes a dependent child of
another family. Proposed section 10HA sets out when a child will have
reached the safety net threshold, while proposed section 10HB sets out
when the child’s family members will be considered to have reached the
threshold. A child will reach the threshold when the total expenditure for
services relating to the child reaches the threshold (regardless of which
family paid for the services) or where the expenditure for the child combined
with the expenditure for one family exceed the safety-net threshold. A child’s
family members will be considered to have reached the threshold when their own
medical expenses, combined with expenses incurred on the child’s behalf by them
(but not expenses incurred by the other family) exceed the safety-net
threshold. A detailed example of how proposed sections 10HA and 10HB will
work in practice is set out in the Bill. Proposed section 10HC clarifies
the situation where a family has separated part-through a calendar year (and
has become two different families for the purposes of the safety-net) and,
before separating, there were expenses incurred on behalf of the child. Instead
of each family incurring half the expense, which would be the case under
subsection 10AC(3), the total amount incurred by the former family will apply
to each new family (regardless of which parent paid for the service). A
scenario explaining proposed section 10HC is included in the Bill.
Proposed subdivisions K and L specify the treatment
and eligibility of confirmed and unconfirmed singles. Currently sections 10AD
and 10ADA prescribe the circumstances under which an individual can reach the
safety set. An individual is defined as a person who is not a member of a
registered family.[97]
The Bill introduces the concept of confirmed singles and
unconfirmed singles. New section 10K allows for a person to give the CEM
a notice that they wish to be treated as a confirmed single. Similar to the
provisions in relation to registered families (see above discussion of proposed
subsections 10FA(1) and (2)), the CEM must request that a person provide
confirmation where the CEM reasonably believes that the person may in the near
future be eligible for a safety net benefit amount if the person were a
confirmed single.[98]
Proposed subsections 10KA(4)-(6) provide for time limits in which a person
can confirm that they wish to be treated as a confirmed single and still
qualify for the safety net for that year. New section 10KB provides for
the situation where a confirmed single becomes a member of a registered family
and before joining the family had reached the safety net. Proposed
subsection 10KB(2) limits the classes of people who can be considered to be
a member of the confirmed single’s family for that calendar year to only them
and their dependent children (therefore if the confirmed single acquires a
spouse, the spouse will not be considered to be part of their family for that
calendar year). According to the Explanatory Memorandum, the purposes of these
amendments ‘is to prevent a family from seeking to take advantage of the
safety-net arrangements by confirming one member as a confirmed single, then
subsequently adding a spouse to the family who would benefit from the confirmed
single’s out of pocket expenses’.[99]
New subdivision L sets out the circumstances where
a person is considered to be an unconfirmed single. Specifically, where a
person is not a confirmed single or a member of a confirmed family, or eligible
for concessional benefits or family tax benefits (see below discussion), the
person will be considered to be an unconfirmed single. This clarifies that
anyone who does not fall into those four categories will still be eligible to
reach a safety net threshold (as prescribed under new Subdivision D).
Proposed subdivision M deals with the treatment of
FTB(A) members and proposed subdivision N deals with concessional
persons.
Currently the HIA only provides for a definition of a
FTB(A) family. Subsection 8(1A) defines a FTB(A) family to mean a registered
family which includes a member who has received an instalment payment of a
family tax benefit that has a Part A rate that is greater than nil,[100]
or who has received a lump-sum FTB(A) payment for a past financial year, or
where a determination has been made which provides that the registered family
is a FTB(A) family. The Bill removes the current definition of a FTB(A) family
and replaces it with a concept of a FTB(A) person and a new definition of a FTB(A)
family. Proposed section 10M provides that FTB(A) person is a person who
has received an instalment payment of a family tax benefit that has a Part A
rate that is greater than nil, or who has received a lump-sum FTB(A) payment
for a past financial year, or where the Minister has made a determination
providing that the person is considered to be a FTB(A) person for the purpose
of the safety-net. This new definition is effectively the same as the current
definition of a FTB(A) family except it allows for FTB(A) recipients who are
not part of a registered family to be eligible for the FTB(A) safety-net
threshold. Proposed section 10MA provides that where a member of a
registered family receives FTB(A), then every member of the family is given
access to the FTB(A) threshold. This is the same as the existing situation for
a FTB(A) family.
Under the HIA, a concessional person is a person
who is the holder of (or who is listed on) a pensioner concession card, a
seniors health card or a health care card or a person who is entitled to
concessional benefits under the Veterans’ Entitlements Act 1986 or the Military
Rehabilitation and Compensation Act 2004.[101]
A person who is a Commonwealth concession card holder at any time in the
calendar year retains concessional status for the rest of the calendar year. Proposed
section 10N retains the current definition of a concessional person.
Proposed subdivision P specifies the expenses that
will count towards the safety net thresholds.
Proposed section 10P specifies how to calculate a
person’s accumulated safety net expenses, including the maximum amount that can
be counted towards the safety net. In simple terms, this provision introduces a
maximum out of pocket expense amount (or cap) that can accumulate towards the
safety net. Under current arrangements, there is no cap on out of pocket costs
that can count towards the safety net. Consequently, a person can reach the
current safety net threshold if they incur high out of pocket costs from only a
few services.
Proposed subsection 10P(1) specifies that the amount
of the safety net expenses for a safety net service is defined as either, the
out of pocket expense for the service (as defined at proposed subsection 10DB),
or, if this exceeds the prescribed maximum amount (or cap), then no more than
that maximum (cap). That is, only the lower of these two amounts can count
towards the safety net. Proposed subsection 10P(2) specifies a formula
for determining the maximum amount (cap) that can count towards the safety net.
This is the threshold percentage (defined at proposed 10P(3) as 150 per
cent of the schedule fee) multiplied by the fee for the service (defined at proposed
10P(3) as the Medicare schedule fee, or an amount prescribed under
regulation) minus the Medicare benefit. The EM provides a useful example.[102]
However, a second example provided in the EM appears to have been worked
incorrectly.[103]
The second example with corrected working would seem to be:
a patient visits their doctor and is charged $200. The schedule fee is $80 and
the Medicare benefit is $68. Therefore the out of pocket expense is $132 ($200–$68).
The maximum amount that can be counted towards the safety
net is:
150%×$80)–$68=$52.
Even though the patient was $132 out of pocket, only $52 of
this will count towards their safety net threshold.
Proposed subsection 10Q specifies that, for a safety
net amount to be payable, a specified (or minimum) amount must first be paid
for the service. This amount is at least the difference between the fee charged
by the medical provider and the Medicare benefit. In most instances, the
patient would pay at the time of the service; this provision ensures that a
minimum amount has been rendered for a service before a safety net benefit can
be paid.
Proposed subdivision R specifies the methodology for
calculating the safety net benefit amount and the maximum (cap) on safety net
benefits, once the safety net threshold is reached. Under the existing safety
net arrangements the amount of benefits are capped to 300 per cent of the
Medicare fee for that service (up to a maximum of $500). Under the proposed
provisions this cap will be reduced to 150 per cent of the Medicare fee.
Proposed subsection 10R(1) specifies that the safety
net benefit is the lesser of the ‘adjusted expenses’ for that particular
service or the maximum safety net amount. This approach is broadly similar to
current provisions, except that it reduces the safety net percentage. There are
different formulae to be applied depending on the type of safety net expense
(the ‘adjusted expense’): one for when the safety net threshold is reached, and
one for when a person is close to reaching the threshold.[104]
The first of these formulae is at proposed section 10R(2) which specifies
the formula for calculating the adjusted expenses when the safety net threshold
has been reached. This is equal to 80 per cent of the difference between the
fee paid by the patient and the Medicare benefit (i.e. 80 per cent of the out
of pocket expense). Proposed subsection 10R(3) specifies the second
formula in the event a person is just below the safety net threshold, but would
reach the threshold if the current service were included. This formula
calculates 80 percent of the out of pocket expense that is left over for the
service once the threshold has been reached.
The maximum safety net benefit amount is calculated using a
formula at proposed subsection 10R(4).This is specified as the safety
net cap percentage (defined as 150 per cent at proposed section 10R(6))
multiplied by the schedule fee for the service,[105]
minus the Medicare benefit. The EM provides one useful example. [106]
However, a second example provided in the EM appears to have been worked
incorrectly.[107]
The second example with corrected working would appear to
be: a patient visits their doctor and is charged $200. They have already
reached their safety net for the year. The schedule fee for the service is $80
and the Medicare benefit is $68. Therefore the out of pocket expense is $132
($200–$68). The safety-net cap percentage is 150 per cent.
Adjusted expenses are 80% of $132 which is $105.60.
The maximum safety-net amount for the service is:
150%×$80)–$68=$52.
As the adjusted expense is greater than the maximum
safety-net amount, the person will only receive a safety net benefit of $52
(plus the Medicare benefit of $68, for a total benefit of $120). This leaves
them out of pocket by $80, despite having reached the safety net threshold.
Proposed subsection 10R(6) provides definitions of
terms to apply under these provisions, including the treatment of multiple
professional services at proposed paragraph 10R(6)(b).
Proposed subdivision S deals with indexation matters.
Proposed section 10S specifies the indexation number
to be used is the Consumer Price Index (CPI) and that indexation for a safety
net service is to occur on 1 January each year, which is consistent with
indexation arrangements that currently apply to the safety net.[108]
The Bill simplifies existing Medicare safety net
arrangements and lowers the safety net thresholds for many people. It goes a
long way in recognising that the composition of a family has changed over time
and that there has been a substantial increase in lone-person
households.[109]
This may increase the number of people who are assisted by safety net
benefits. However, in cases where health professionals charge fees that are
significantly higher than the schedule fee, patients will not be able count all
of their out of pocket costs towards the safety net, and will receive lower safety
net benefits once they do reach the threshold. Thus, the safety net will cover
more people, but for less money overall, making it a savings measure.
Stakeholder responses have focused on the concerns about
increased out of pocket costs for some patients. The Government is expecting
the revised arrangements to exert downward pressure on high doctors’ fees, but
if this does not eventuate then some patients will pay more. Removing the GPG will
also increase gap costs for services that have a very high Medicare schedule
fee, because the maximum dollar value of the gap will no longer be capped.
The proposed changes to safety net arrangements are likely
to interact with other Government initiatives such as the extended indexation
pause on Medicare schedule fees and the MBS review that is currently underway. This
interaction may warrant further review or scrutiny before the safety net
reforms are enacted.
The evidence base around some of the claims remains
limited (although additional material provided to the Senate Community Affairs
Committee by the Department will assist), but uncertainty remains over the
extent of perverse billing practices for out of hospital treatments and the
extent to which safety net benefits are being inequitably distributed.
Questions also remain over whether the bill will address all the problems that
have been identified and deliver the savings that are forecast.
Members, Senators and Parliamentary staff can obtain
further information from the Parliamentary Library on (02) 6277 2500.
[1]. Health Insurance Act
1973, accessed 29 October 2015.
[2]. A
confirmed single is someone who has confirmed their single status with Medicare
Australia. The confirmation process is specified in new subdivision K.
[3]. New
subdivision L specifies that an unconfirmed single is someone who has not
confirmed their status with Medicare Australia and is not a concessional card
holder, not an FTB(A) person or a person confirmed as part of a family.
[4]. Other
examples are described in the Explanatory
Memorandum, Health Insurance Amendment (Safety Net) Bill 2015, pp. 6–7,
accessed 3 November 2015.
[5]. Department
of Health (DoH), ‘Quarterly
Medicare statistics’, DoH website, updated 14 August 2015, accessed 21
October 2015.
[6]. Health
Insurance Act 1973, subsection 10(2).
[7]. The
1946 Constitutional amendment which gave the Commonwealth powers to provide
medical, dental and pharmaceutical benefits placed a restriction on these
powers, ‘but not so as to authorise any form of civil conscription’ (Australian
Constitution, subsection 51 (xxiiiA)). This has been interpreted so as to
prevent the Commonwealth from setting doctors’ fees.
[8]. DoH,
‘Meeting
the Extended Medicare Safety Net (EMSN) threshold’, DoH website, 21 October
2015, accessed 29 October 2015.
[9]. Out
of hospital services include GP and specialist attendances, services provided
in private clinics, and many pathology and diagnostic imaging services. Services
at day surgery facilities are normally classified as a hospital service.
[10]. DoH,
Medicare
Benefits Schedule book, operating from 01 November 2015, DoH, Canberra,
2015, p. 18, accessed 3 November 2015.
[11]. A
Biggs, ‘GP
co-payment proposal: lessons from the past’, Flagpost, Parliamentary
Library blog, 30 April 2014, accessed 21 October 2015.
[12]. Department
of Human Services (DHS), ‘2015
Medicare Safety Net thresholds’, DHS website, updated 9 January 2015, accessed
21 October 2015.
[13]. DoH,
‘Extended
Medicare Safety Net’,
MBS Online website, updated 23 March 2015, accessed 21 October 2015.
[14]. Ibid.
[15]. Centre
for Health Economics Research and Evaluation (CHERE), Extended
Medicare Safety Net review report 2009, report prepared for the
Department of Health and Ageing (DOHA), DOHA, Canberra, 2009, accessed 21
October 2015.
[16]. CHERE,
Extended
Medicare Safety Net: review of capping arrangements report 2011, report
prepared for DOHA, DOHA, 2011, accessed 21 October 2015.
[17]. A
Biggs, Health
Insurance Amendment (Extended Medicare Safety Net) Bill 2014, Bills
digest, 71, 2013–14, Parliamentary Library, Canberra, 2014, accessed 23 October
2015.
[18]. CHERE,
Extended Medicare Safety Net: review of capping arrangements report 2011,
op. cit., p. 21.
[19]. S
Ley (Minister for Health), Fairer,
simpler Medicare safety net to help more patients, media release, 22 October
2015, accessed 23 October 2015.
[20]. It
is not clear if the contribution of the OMSN to safety net expenditure is
included in the total figure cited by the Minister, but it would be relatively
modest based on the findings of the 2011 review (see CHERE, 2011, op. cit., p.
22). The $20.3 billion figure is an estimate from Australian Government, Budget
strategy and outlook: budget paper no. 1: 2016, Table 8.1, p. 5-23,
accessed 23 October 2015.
[21]. S
Ley, ‘Second
reading speech: Health Insurance Amendment (Safety Net) Bill 2015’, House
of Representatives, Debates, (proof), p. 5, 21 October 2015,
accessed 23 October 2015.
[22]. S
Ley, Fairer, simpler Medicare safety net to help more patients, op. cit.
[23]. National
Health and Hospitals Reform Commission (NHHRC), A
healthier future for all Australians: final report (Bennett Report),
DOHA, Canberra, June 2009, p. 7, accessed 21 October 2015.
[24]. NHHRC,
op. cit., p. 236. Note the NHHRC was referring to both the Medicare and the
Pharmaceutical Benefits Scheme safety nets.
[25]. H
Alexander, J Medew and D Harrison, ‘What’s
really going on with health costs’, The Age, 24 January 2015, p. 26, accessed 22
October 2015.
[26]. DoH,
‘Quarterly
Medicare Statistics’, op. cit., June quarter 2015, Table 1.1a,
accessed 22 October 2015.
[27]. Ibid.,
Table 1.5.
[28]. A
Stuart (Deputy Secretary, Health Benefits Group, Department of Health),
Evidence to Senate Community Affairs Legislation Committee, Official
committee Hansard, 21 October 2015, p. 35, accessed 18 November 2015.
[29]. S
Ley, ‘Transcript
of press conference: Sydney: 22 April 2015: Review of Medicare’,
transcript, 22 April 2015, accessed 23 October 2015.
[30]. S
Ley, ‘Abbott
Government to deliver a healthier Medicare’, media release, 22 April 2015, accessed 23
October 2015.
[31]. S
Ley, ‘Establishment of expert
groups to shape a healthier Medicare’, media release, 4 June 2015, accessed 23 October 2015.
[32]. Explanatory
Memorandum, op. cit., p. 7.
[33]. Australian
Government, Budget
measures: budget paper no. 2: 2014–15, p. 145, accessed 21
October 2015.
[34]. Ibid.
[35]. Selection
of Bills Committee, Report,
14, 2015, The Senate, 12 November 2015.
[36]. Senate
Community Affairs Legislation Committee, ‘Inquiry
into the Health Insurance Amendment (Safety Net) Bill 2015 homepage’, Parliament
of Australia website, accessed 17 November 2015.
[37]. Senate
Community Affairs Legislation Committee, Inquiry
into the provisions of the Health Insurance Amendment (Safety Net) Bill 2015,
The Senate, Canberra, 2015, accessed 24 November 2015.
[38]. Ibid.,
p. 25.
[39]. Senate
Standing Committee for the Scrutiny of Bills, Alert
digest, 12, 2015, The Senate, 11 November 2015, p. 13, accessed
18 November 2015.
[40]. C
King (Shadow Minister for Health), ‘Tony
Abbott's GP Tax: attack on Medicare begins’, media release, 14 May 2015, accessed
21 October 2015.
[41]. C
King, ‘Upfront
GP tax will break the bank for cancer patients’, media release, 9 October
2014, accessed 21 October 2015.
[42]. C
King, ‘Abbott
hiding new health cuts from Canning voters’, media release, 14 September 2015, accessed
21 October 2015.
[43]. C
King, ‘Labor
to carefully scrutinise Medicare Safety Net changes’, media release, 21
October 2015, accessed 2 November 2015.
[44]. C
King, ‘Medicare
safety net needs real reform, not more Liberal health cuts’, media release,
10 November 2015, accessed 17 November 2015.
[45]. R
Di Natale, ‘Greens
to move inquiry into out-of-pocket healthcare costs’, media release, 7 August 2013, accessed 21
October 2015.
[46]. R
Di Natale, ‘Committees:
Community Affairs References Committee: Reports’, Senate, Debates, 26 August 2014, p.
5607, accessed 21 October 2015.
[47]. S
Dunlevy, ‘Health
bills set to jump’, The Mercury, 14 September 2015, p. 5, accessed 2
November 2015; N Xenophon, ‘Mamma
Mia!: Government's proposed Medicare Safety Net changes will cost IVF couples
almost $2000 a year more’, media release, 14 September 2015, accessed 2
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[48]. Senate
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[85]. Ibid.,
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[86]. Ibid.
[87]. Health
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[88]. That
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multiple services counting towards the safety net, regulations can specify
these are to be treated as a single service.
[89]. Subsections
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[90]. An
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which explains that the process for confirmation is specified in proposed
subdivision K, while an unconfirmed single is defined in proposed
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[91]. DoH,
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[98]. Proposed
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[103]. Ibid.,
pp. 25–26.
[104]. Expenses
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[107]. Ibid.,
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