An Introduction to Medicare Australia and the Medicare Benefits Schedule

V1.1 \ December 2017

The Australian health care system • Free treatment and accommodation as a public patient in a public hospital. • The Australian Government has the primary role of developing national policies, • 75 per cent of the Medicare Schedule fee for regulations and funding. services and procedures as an inpatient in a private hospital or a private patient in a public • Australia’s public hospital system is jointly hospital. This does not include hospital funded by the Australian Government and accommodation and items such as theatre state and territory governments. fees and medicines. • State, territory and local governments are responsible for the delivery and management Medicare provides to health of public health services and for maintaining professionals: direct relationships with most health care providers, including the regulation of health • Assesses and pays Medicare benefits to professionals and private hospitals. eligible members of the public for medical services. Medicare Australia • Registers the details of eligible health professionals to have Medicare benefits paid Medicare Australia works in partnership with the for their services. Australian Government of Health (DoH) to deliver the Australian Government’s health policy • Detects and prevents fraudulent use of the objectives, eg: Medicare program.

• Expanding and reforming the mental health Health professional activity care system. Any medical practitioner or other health • Investing in new immunisations and professional billing through the Medicare program medicines. is required to have a Medicare provider number. • Providing financial incentives to general practitioners who bulk-bill Commonwealth A Medicare provider number identifies the Concession Card holders and children under practitioner and their eligibility to provide certain 16 years of age. services. They are:

Medicare provides access to patients • Location specific. for: • Used to refer to or request additional clinical services, eg specialists, X-ray, pathology, etc. • Free or subsidised treatment by health • Used to access Medicare Benefits Schedule professionals such as doctors, specialists, (for billing). optometrists, dentists, and in special circumstances, other allied health • Issued with effective dates. practitioners.

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Provider eligibility for Medicare Common general practice consultation items

To be eligible to provide medical services which MBS Group MBS Group A2 will attract Medicare benefits, medical A1 practitioners must meet one of the following criteria: Consult Item MBS Fee Item MBS No. No. Fee • Be a recognised specialist, consultant Brief – 3 $16.95 52 $11.00 physician or general practitioner; or Level A • Be in an approved placement under section 3GA of the Health Insurance Act 1973 (such Standard – 23 $37.05 53 $21.00 as the Rural Locum Relief Program or Level B WAGPET); or Long – 36 $71.70 54 $38.00 • Be a temporary resident doctor with an Level C exemption under section 19AB of the Health Prolonged - 44 $105.55 57 $61.00 Insurance Act 1973, and working in accord Level D with that exemption (ie working in a District of MBS fees and items current at 23 August 2017 Workforce Shortage). and are subject to change.

Medicare rebates Medicare pays for:

Medical practitioners who do not hold a • An examination on a patient, to check on and recognized specialist qualification or vocational provide advice on their general health. recognition (VR) in general practice will only be eligible to access Medicare benefits and rebates • A clinically relevant service which is generally at the lower scale, or Group A2 of the MBS. accepted by the profession as being necessary for the appropriate treatment of the • Group A2 item descriptors are very similar to patient. Group 1 MBS items; Medicare does not pay for: • Fees and benefits are financially less; • Enrolling on the Rural Other Medical • Surgical removal of a tattoo. Practitioner Program Scheme (ROMPS) • An eye exam for a pilot’s license medical. enables eligible non-VR medical practitioners • Writing a report for a life insurance medical. to access Group A1 MBS rates. Applicants for the ROMPS must: • Services where the expense is the responsibility of the patient’s employer, or ▪ Express an interest in achieving VR in other third party. general practice; and ▪ Be providing services in Rural, Remote, Medicare rebates and billing styles Metropolitan Area (RRMA) classifications 4- 7. There are various ways general practitioners may charge for a consultation. For example: Medicare Benefits Schedule Item 23 (Level B): 100 per cent of the Schedule The Medicare Benefit Schedule is an Australian fee is $37.05 Government Department of Health publication. It contains a list of the services subsidised by the Australian Government through the Medicare system. Access MBS online for specific items. a) A general practitioner may ‘bulk-bill’ a patient, effectively charging only the Schedule fee directly to Medicare leaving the patient with $0 to pay. Common for concession card holders and children under 16.

b) A general practitioner may charge the patient a ‘private fee’ upfront circa $70. The patient pays the fee on the day of service, and then claims the ‘rebate’ from Medicare. The patient’s out of pocket, the ‘gap’, being the difference between the private fee and the rebate. In this case $32.95.

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Patient eligibility Pharmaceutical Benefits Scheme Under the Health Insurance Act 1973, a patient is prescriber number deemed eligible to access Medicare if they: Medical practitioners eligible to prescribe medications under the PBS are issued with a • Are an Australian permanent resident or an prescriber number, usually the first time they are eligible overseas representative. issued with a Medicare provider number. • Have been declared eligible by a Ministerial Order. Unlike a Medicare provider number which is location specific and has set dates, a medical • Are visiting from a country with which practitioner is only issued with one prescriber Australia has a Reciprocal Health Care number. Agreement (RHCA), such as New Zealand, United Kingdom, Republic of Ireland, the An application for a prescriber number can be Netherlands, Finland, Italy, Belgium, Malta, made during the initial application for a Medicare Slovenia and Norway. provider number (if applicable) or as a separate application. The Medicare card Before an eligible person can access free or More information subsidised health care treatment in Australia, they Medicare Australia offers: must first be issued with a valid Medicare number. • eLearning packages for new health professionals. • An overview of the MBS primary care items. • Medicare requirement for billing the treatment and removal of skin lesions. • Advanced, case-based eLearning for general practitioners when providing GP Management Plans and Team Care Arrangements. • Quick reference guides. • Handbooks.

Department of Human Services The Medicare card denotes: Medicare for Health Professionals http://medicareaust.com/Accessible/MBS/NewHea • Name of person lthProfessionals/WCAGWelcome/index.html • Medicare number – a ten-digit number which identifies the cardholder and their family References group. The last digit identifies the issue Department of Human Services number of the card. https://www.humanservices.gov.au/health- • Expiry date – date the card is valid to. professionals?utm_id=9 • Reference number (prior to name) – identifies Department of Health, Medicare Benefits the number on the card. Schedule http://www.mbsonline.gov.au/internet/mbsonline/p Services not attracting Medicare ublishing.nsf/Content/Home benefits: Department of Health • Provided by a non-Medicare eligible health http://www.health.gov.au/ professional • Provided to a non-Medicare eligible patient • Non-MBS items, such as bandages or dressings Health professionals can still raise a private invoice for items not covered by the MBS, however it is an offence not to advise a patient that a Medicare rebate will not be payable.

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