Grampians MBS Industry Advisor Project 2012-13

FACT SHEET

The Medicare Benefits Scheme: A source of public funding for health services

About Medicare Medicare is a universal health insurance scheme financed through taxation. The scheme was introduced by the Commonwealth for the first time in 1974 as Medibank, and then re-introduced in 1984 as the Medicare Benefits Scheme. The stated objectives of the scheme are:

1. To make health care affordable for all Australians 2. To give all Australians access to health care services with priority according to clinical need, and 3. To provide a high quality of care1.

Is Medicare a private sector scheme? The facts are that

 It is illegal for a health provider or health service that is already funded by a government to provide a distinct health service to also bill Medicare to pay for that service; and  It has been predominantly providers in the private sector that have registered with Medicare to attract rebates for their clients.

Nevertheless, the Medicare Benefits Schedule is a publicly funded health care system that can and has been utilised by providers working within community health services to attract funding to deliver more health services for decades. A key legal consideration is to avoid ‘double dipping’. Double dipping means having a distinct occasion of health service funded both through the State government and Medicare Australia at the same time (being paid or subsidised by government funding twice for the same service).

Community health services are free to explore opportunities to design sustainable service delivery models that attract MBS benefits, avoid ‘double dipping’ and also adhere to core organisational values such as equity of access and a social model of health approach.

More information about Medicare Under the scheme, a list of services and procedures that attract a Medicare benefit are listed on a schedule of fees – the Medicare Benefits Schedule (MBS). The MBS subsidises the consumer for each service rendered if that service is listed on the schedule. A health provider wishing to attract Medicare benefits for the services they offer must register with Medicare and meet Medicare’s requirements for registration - for example, qualifications and membership of their relevant professional college/organisations. They are then required to apply for a unique individual Medicare Provider Number for each geographical address from which they wish to attract Medicare benefits.

1 Medicare Australia. 2012. www.medicareaustralia.gov.au/provider/medicare/index.jsp Accessed 1st September 2012. Grampians MBS Industry Advisor Project 2012-13

Once registered, providers are free to set their own fees and other billing policies, though they may voluntarily agree to abide by billing policies established by the organisation for whom or with whom they work. Fees charged by a provider may:

(a) Fully cover the cost of the service if the provider decides to bulk bill, which means asking the consumer to consent to assigning their Medicare benefit directly to the provider. If the consumer does so, they thus receive a ‘free’ service and it is illegal under Commonwealth law for the provider to charge a co-payment with very limited exceptions;

(b) Partially cover the cost of the service if the provider decides to privately bill, which means asking the consumer to pay the full cost of the service up front and providing them with the means necessary to claim their Medicare benefit. If the consumer has registered their bank details with Medicare and if the provider has the appropriate EFTPOS facilities, the consumer can be reimbursed by Medicare Australia immediately into their bank account; if not, the consumer can take their receipt to a Medicare office for reimbursement.

Medicare has traditionally focused on subsidising services provided by medical practitioners (GPs and other medical specialists) and optometrists. Since 2004, a limited range of services delivered by other practitioners have been introduced onto the MBS. The practitioners are: dentists, dental prosthetists, dental specialists, nurse practitioners, midwives, Aboriginal health workers, diabetes educators, audiologists, exercise physiologists, dieticians, occupational therapists, physiotherapists, podiatrists, chiropractors, osteopaths, orthoptists, speech pathologists, psychologists, and clinical psychologists. This broadening of the MBS has offered new opportunities for community health services to ‘tap into’ Medicare to fund or subsidise the cost of providing health services.

Billing under Medicare Like health providers in the private sector, community health services are free to consider and set billing policies in relation to services that attract Medicare rebates. Some organisations decide on a 100% bulk billing policy which means clients do not face any fees. Others try to match Medicare billing policies with the Victorian Department of Health’s Fees Policy for HACC and Primary Health Programs – for example by bulk billing low income earners or charging an $8.80 gap; charging a $13.50 gap for middle income earners; and charging full fees for high income earners. Others decide on a completely new billing policy that may seek to match typical policies set in private general practice and allied health services – for example bulk billing concession card holders, pensioners and children and privately billing everyone else. Each model needs to uniquely suit an organisation in accordance with its client’s needs and the organisation’s values and plans.