This module provides you with an overview of the Australian health care system, focusing on the Medicare program. It briefly explains the eligibility requirements for health care professionals wanting to participate in Medicare. It also outlines which patients are eligible for Medicare and provides information on the conditions under which Medicare benefits can be paid.
At the end of this topic, you will:
The aim of the national health care funding system is to give all Australian residents, regardless of their personal circumstances, access to health care at an affordable cost or at no cost, while allowing choice for individuals through substantial private sector involvement in health care delivery and financing.
The Australian Government’s funding includes three major national subsidy schemes:
Medicare and the Pharmaceutical Benefits Scheme cover all Australian residents and subsidise their payments for private medical services and for a high proportion of prescription medicine.
Australian Government funding of the 30% Rebate and other key incentives support people’s choice to take up and retain private health insurance.
Under Medicare, the Australian and state governments jointly fund public hospital services so they are provided free of charge to people who choose to be treated as public patients.
The Australian health system is widely regarded as being world-class in terms of its effectiveness and efficiency. The system includes a range of funding and regulatory mechanisms and a mixture of public and private sector health services.
Medicare Australia works in partnership with the Department of Health and Ageing (DoHA) to achieve the Australian Government’s health policy objectives.
DoHA is responsible for the policy development of Medicare.
Medicare Australia is responsible for:
Medicare provides access to:
Medicare was introduced in 1984 to provide eligible Australian residents with affordable, accessible and high quality health care.
It was established based on the understanding that all Australians should contribute to the cost of health care according to their ability to pay, and is financed through progressive income tax. An income related Medicare levy ensures all Australians have access to free or low cost health and hospital care while being free to choose private health services and in special circumstances allied health services.
Medicare enrolments and Medicare benefit payments are administered by Medicare Australia through electronic channels and its network of Medicare offices.
Australia’s public hospital system is jointly funded by the Australian Government and state and territory governments, and is administered by state and territory health departments.
Medicare Australia is an Australian Government agency aiming to improve the health and well being of Australians by delivering information and payment services.
Medicare is Australia’s universal health insurance scheme and was introduced in 1984. Its objectives are to provide eligible Australian residents with affordable, accessible and high-quality care.
At the end of this topic, you will:
Provider numbers are unique numbers issued by Medicare Australia to registered health care professionals including medical practitioners, optometrists, dental practitioners and allied health professionals. They are used by Medicare Australia to identify health care professionals.
As a health care professional you must have a provider number for every location at which you practise. If you move to a new practice location, you must apply for a provider number for that new location.
The provider number is comprised of three components:
Dr Jones has three different practice locations in Smithtown. Medicare Australia has issued provider numbers for each of these locations. Every Friday Dr Jones practises at the Mexican Street practice.
When claiming Medicare benefits for his work on Fridays, Dr Jones should use the provider number relating to his Mexican Street practice.
Apart from uniquely identifying you and the physical location from which you practise, a provider number may be used to:
A provider number does not necessarily mean you can attract Medicare benefits for the services you provide.
Before a health care professional can attract a Medicare benefit, they must satisfy legislative requirements set out in the Health Insurance Act 1973.
IMPORTANT
Where there is no entitlement to Medicare benefits for a particular service it is important to inform
the patient. It is an offence under the Health Insurance Act 1973 to provide a service without
first informing a patient when a Medicare benefit is not payable for that service.
If you have questions about your eligibility to access Medicare benefits for services you provide, you should call the Medicare provider enquiry line on 132 150 (call charges apply).
Dr Jones’ provider eligibility dates with Medicare Australia are from 1 August 2008 to 31 September 2008.
The practice manager says: "Dr Jones are you able to commence practising here on the 25 July 2008 as the surgery is very busy?"
Dr Jones replies: “while I can commence practise on 25 July, I am unable to claim Medicare benefits prior to the 1st August 2008. Medicare Australia has advised me that it is a serious offence for me to carry out services without first informing patients when a Medicare benefit is not payable for the services provided”
To enable the payment of Medicare benefits, all accounts lodged with Medicare Australia must include your name and either:
To refer your patients to specialists, or request diagnostic imaging or pathology services, your referral letter must include your name and either:
IMPORTANT
It is recommended that you include your name, your provider number and your address to ensure prompt
payment of Medicare benefits.
Make sure you notify Medicare Australia promptly when you stop practising from a specific location. If you don’t, another person who knows your provider number could misuse your number, possibly resulting in a misdirection of Medicare payments or other information.
A locum is a person who temporarily fulfils the duties of another.
As mentioned earlier, a health care professional must have a provider number for every location at which he/she practises.
However, in some cases a locum may be able to use one of their existing provider numbers when practising in another location for a short period of time. If this situation is likely to occur in your practice, you should contact the Medicare Providing Eligibility section on 132 150 for guidance.
You will now hear four statements. Two statements are correct and two are incorrect. Please try to choose the correct statements.
The following are correct statements:
The following are incorrect statements because:
At the end of this topic, you will:
Under the Health Insurance Act 1973, entitlement to Medicare benefits is extended to eligible persons.
A person who is eligible for Medicare under the Health Insurance Act :
Australian residents: Australian citizens, the holders of permanent resident status and some applicants for permanent resident status who reside in Australia are eligible for a Medicare card. Residents of Norfolk Island are not eligible for enrolment in Medicare.
Eligible overseas representatives
Government agencies post permanent officers overseas for varying periods of time to act as agency representatives, they remain eligible for Medicare as they are Australian citizens.
Ministerial Orders
The Health Insurance Act allows the Minister to order a particular person or group of persons to be regarded as eligible for enrolment in Medicare, even though when applying, the usual eligibility rules would not regard them as eligible.
Reciprocal Health Care Agreements: The Australian Government has signed a Reciprocal Health Care Agreement (RHCA) with the governments of several countries which entitles residents of these countries to limited subsidised health services for necessary medical treatment while visiting Australia. The entitlements and periods of cover under these agreements vary for different countries.
Newborn babies: Newborn babies are eligible for Medicare, once eligibility of at least one parent, proof of birth and Australian residency requirements have been met and provided to Medicare Australia.
More information on patient eligibility can be found in Mediguide - Medicare Australia’s publication for health care professionals and practice staff.
To view Mediguide online, navigate to the following link: www.medicareaustralia.gov.au/mediguide
Eligible persons must enrol with Medicare before they can receive a Medicare card and Medicare benefits.
In most cases, a patient requires a valid Medicare number in order to access Medicare rebates for private health care professional’s accounts or when seeking treatment as a public patient in a public hospital.
Reading the Medicare card
The Medicare card is comprised of three key components (11 numbers in the three parts that uniquely
identify each person, name and the expiry date).
Component 1: part a
Stem is the first nine digits and identifies the card holder and their family groups.
Component 1: part b
Card issue number is the last (10th) digit and identifies the latest issue number of the holder
- for example, issue 8 is a later card than issue 7.
Component 1: part c
Reference number identifies the person named on the card.
Component 2
Name of person.
Component 3
Expiry date (date to which the card is valid).
In addition, where the card is used for an eligible overseas visitor or an applicant for permanent residence, either ‘Reciprocal health care Visitor’ or ‘Interim card’ will also appear on the card.
IMPORTANT: you will need to be able to quote the patient’s Medicare number in order to utilise some of the billing methods available with Medicare Australia.
You will now hear three statements. Only one statement is correct. Please try to choose the correct statement.
The following is the correct statement:
The following are incorrect statements because:
A person who is eligible for Medicare under the Health Insurance Act 1973:
With the exception of certain eligible overseas visitors, your patient must have a valid Medicare number in order to access Medicare rebates for private health care professional’s accounts or when seeking treatment as a public patient in a public hospital.
There are three different Medicare cards for groups of eligible people. Each variation of the Medicare card will allow the person access to certain Medicare services for a designated period of time. The duration of cover, and in some instances the Medicare services that can be accessed by the person, can differ between these three cards.
Well done. You have successfully completed the What is Medicare? e-Learning module.
You now know that:
To send an email to the Medicare Education mailbox contact the following:
medicare.education@medicareaustralia.gov.auMedicare Australia values your feedback. To provide feedback about this module complete the following survey:
http://www.zoomerang.com/Survey/?p=WEB2282HLN9P6Q.Back to page top