An introduction to Medicare Australia and the Medicare Benefits Schedule Version 4 November 2014
Overview: 1. Medicare: Australia s universal health care program 2. Medicare for health professionals a. Medicare provider numbers b. Health professional eligibility 3. Patient eligibility a. Medicare cards and numbers 4. The Medicare Benefits Schedule a. Medicare Benefit fees b. Medicare rebates and billing styles c. What Medicare will and will not pay for
The Australian health care system State Government Provides free public health services through the public hospital system eg WA Country Health Service Federal Government Responsible for primary health care such as: Medicare Australia eg Private general practice, 19(2) billing access Pharmaceutical Benefit Scheme (PBS)
Medicare Australia Works in partnership with the Australian Government Department of Health (DoH) to deliver the Australian Government s health policy objectives For example: Expanding and reforming the mental health care system including the introduction of two time-based mental health item numbers Investing in new immunisations and medicines Providing financial incentives to GPs who bulk bill Commonwealth Concession Card holders and children under 16 years of age
The Medicare Program Was introduced in 1984 to provide eligible Australian residents with affordable, accessible and high quality health care Provides free treatment as a public hospital patient Provides free or subsidised treatment by health professionals such as your GP, optometrist or nurse practitioner
For health professionals: Medicare Australia Registers the details of health professionals eligible to have Medicare benefits paid for their services Assesses and pays Medicare benefits to eligible members of the public for medical services Detects and prevents fraudulent use of the Medicare program
Health Professional Activity Any medical practitioner or other health professional billing through the Medicare program is required to have a Medicare provider number A Medicare provider number identifies the practitioner and their eligibility to provide certain services. They are: Location specific Issued with effective dates Used to refer to or request additional clinical services, eg specialists, X-Ray, pathology, etc Used to access Medicare Benefits Schedule (billing)
Provider eligibility for Medicare To be eligible to provide medical services which will attract Medicare benefits, medical practitioners must meet one of the following criteria: Be a recognised specialist, consultant physician or general practitioner; or Be in an approved placement under section 3GA of the Health Insurance Act 1973 (such as the Rural Locum Relief Program or WAGPET); or Be a temporary resident doctor with an exemption under section 19AB of the Health Insurance Act 1973, and working in accord with that exemption (working in a District of Workforce Shortage).
Medicare rebates Medical practitioners who do not hold a recognised specialist qualification or vocational recognition in general practice will only be eligible to access Medicare benefits and rebates at the lower scale, or Group A2 of the MBS. Group A2 items are very similar to Group A1 MBS items; Fees and benefits are financially less; Enrolling on the Rural Other Medical Practitioners Program (ROMPs) enables non-vr medical practitioners to access Group A1 MBS rates; The medical practitioner must express an interest in achieving a VR in general practice; and Be providing services in Rural, Remote Metropolitan Area (RRMA) classifications 4-7.
Medicare Benefits Schedule The Medicare Benefit Schedule (MBS) is an Australian Government Department of Health publication. It contains a list of the services subsidised by the Australian Government through the Medicare system Item Number Descriptor Schedule fee and rebate Explanatory notes
Standard consultation MBS items MBS Group A1 MBS Group A2 Item number MBS Fee Item number MBS Fee 3 brief consult $16.95 52 brief consult $11.00 23 standard $37.05 53 standard $21.00 36 long consult $71.70 54 long consult $38.00 44 prolonged $105.55 57 prolonged $61.00 MBS fees and items current at 1 November 2014 and are subject to change
Medicare rebates and billing styles There are various ways your health professional may charge for a consultation. For example: b) A GP may charge a private rate circa $70 Item 23: 100 per cent of the Schedule fee is $37.05 a) A GP may bulk-bill, effectively charging the Schedule fee directly to Medicare leaving the patient with $0 to pay Patient claims the rebate from Medicare Gap payment difference $32.95 c) A GP may charge the Schedule fee only Patient claims the Schedule or rebate from Medicare Gap payment difference $0
PBS Prescriber Number Medical practitioners eligible to prescribe medications under the Pharmaceutical Benefits Scheme are required to be issued with a Prescriber Number Unlike a Medicare Provider Number which is location specific and has set dates, a practitioner is only issued with one Prescriber Number An application for a Prescriber Number can be made during the initial application for a Medicare Provider Number (if applicable) or as a separate application.
Patient Eligibility Under the Health Insurance Act 1973, a patient is deemed eligible to access Medicare if they: Are an Australian Permanent Resident or an eligible overseas representative Have been declared eligible by a Ministerial Order Are visiting from a country with which Australia has a Reciprocal Health Care Agreement (RHCA). Such as New Zealand, the United Kingdom, the Republic of Ireland, Sweden, the Netherlands, Finland, Italy, Belgium, Malta, Slovenia and Norway.
The Medicare card Before an eligible person can access free or subsidised health care treatment in Australia, they must first be issued with a valid Medicare number Medicare number: A ten digit number which identifies the cardholder and their family group. The last digit identifies the issue number of the card. Name of person Expiry date: Date the card is valid to Reference number: Identifies the person named on the card
Medicare pays: For an examination on a patient, to check on and provide advice on their general health A clinically relevant service which is generally accepted by the profession as being necessary for the appropriate treatment of the patient Medicare does not pay for: Surgical removal of a tattoo An eye exam for a pilot s license medical Writing a report for a life insurance medical Services where the expense is the responsibility of the patient s employer, or other third party
Services not attracting Medicare benefits: Provided by a non-medicare eligible health professional Provided to a non-medicare eligible patient Non-MBS items, such as bandages, dressings or driving medicals for the over 80 s 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.
Medicare Australia offers: More information elearning packages for new health professionals; An overview of the Medicare Benefits Schedule (MBS) primary care items; Medicare requirements for billing the treatment of skin lesions; Advanced, case based elearning for general practitioners when providing GP Management Plans and Team Care Arrangements; Quick reference guides; and Handbooks. Visit : http://www.medicareaustralia.gov.au/provider/business/education/ e-learning.jsp
References: Department of Human Services. www.medicareaustralia.gov.au [online] Viewed 13 November 2014; http://www.medicareaustralia.gov.au/provider/business/education/elearning.jsp Department of Health, Medicare Benefits Schedule. 13 November 2014 Department of Health, www.health.gov.au [online] Viewed 14 November 2014; http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/content/home