Training Module: An Introduction to Medicare Australia Created July 2011
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 2-21
The Australian health care system State Government Provides free public health services through the public hospital system E.g. Country Health Services Federal Government Responsible for primary health care such as: Medicare Australia E.g. Private general practice Pharmaceutical Benefit Scheme (PBS) 3-21
Medicare Australia Works in partnership with the Department of Health and Ageing (DoHA) to deliver the Australian Government s health policy objectives For example, in the 2011-2012 Commonwealth Budget the Government committed to: 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 4-21
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 5-21
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 6-21
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, e.g. specialists, X-Ray, pathology etc Used to access Medicare Benefits Schedule (billing) 7-21
Provider Number Eligibility The Health Insurance Act 1973 (the act) sets out legislative requirements which must be met before a professional service can attract a Medicare benefit. These include: Section 19AB of the act, also referred to as the Ten Year Moratorium Relates to District of Workforce Shortage Section 19AA of the act, also known as accessing an approved 3GA placement Relates to vocational training in general practice; Rural Locum Relief Program (RLRP) 8-21
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. 9-21
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) 10-21
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 11-21
Medicare Benefits Schedule The Medicare Benefit Schedule (MBS) is a Department of Health and Ageing publication. It contains a listing of the Medicare professional services subsidised by the Australian Government Item Number Descriptor Schedule fees Explanatory notes 12-21
Medicare Benefit Fees Medicare benefits are based on a percentage of the 'Fee' for each service as listed in the MBS. In general: Out-patient general practice based attendance items attract a benefit of 100 per cent of the schedule fee Private or public in-patient services attract a benefit of 75 per cent of the schedule fee Allied health or other out-patient services attract a benefit of 85 per cent of the schedule fee 13-21
Medicare Benefit fee percentages Item Number Descriptor Schedule fees Explanatory notes 14-21
Medicare rebates and billing styles There are various ways your health professional may charge for a consultation. For example: Item 23: 100 per cent of the Schedule fee is $34.90 a) A GP may bulk-bill, effectively charging the Schedule fee directly to Medicare leaving the patient with $0 to pay b) A GP may charge a private rate circa $65.00 Patient claims the Schedule or rebate from Medicare Gap payment difference $30.10 c) A GP may charge the Schedule fee only Patient claims the Schedule or rebate from Medicare Gap payment difference $0 15-21
Vocational Register Medical practitioners holding Fellowship with the Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM) can apply for Vocational Recognition Continued vocational recognition is dependent upon: a. the practitioner s service continuing to be predominantly in general practice; and b. the practitioner continuing to meet continuing professional development (CPD) as approved by the RACGP or the ACRRM 16-21
Vocational Register General practitioners on the VR are eligible to access higher paying MBS items from the Group A1 schedule of fees. Practitioners not on the VR use lower fee paying MBS items from the Group A2 schedule of fees Group A1 and A2 have similar, if not identical claimable services. For example, for a professional attendance by a GP in consulting rooms lasting less than 20 minutes the equivalent charges are: Group A1: Item number 23 Fee: $34.90 Benefit: 100% $34.90 Group A2: Item number 52 Fee: $21.00 Benefit: 100% $21.00 17-21
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 18-21
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 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. 19-21
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 Management Plans and Team Care Arrangements; Quick reference guides; and Handbooks. Visit : http://www.medicareaustralia.gov.au/provider/business/education/ e-learning.jsp 20-21
References: Department of Human Services. www.medicareaustralia.gov.au [online] Viewed 28 June 2011; http://www.medicareaustralia.gov.au/provider/business/ education/e-learning.jsp Department of Health and Ageing, Medicare Benefits Schedule. June 2011 Department of Health and Ageing, www.doha.gov.au [online] Viewed June 2011; http://www.health.gov.au/internet/mbsonline/publishing.nsf/content/medicare-benefits- Schedule-MBS-1 21-21