Medicare

Australia has a national health insurance system for all citizens, managed by the Health Insurance Commission. The Health Insurance Commission’s insurance program is known as “Medicare”. Medicare is a government insurance fund paid for out of taxation. The Health Insurance Commission has set what it considers to be a reasonable price for every type of patient consultation and treatment.

When a doctor treats a patient, the doctor can choose to bill the patient at the price set by the Health Insurance Commission. In that case, the patient gives the doctor her/his Medicare card and the doctor bills the Health Insurance Commission directly. This is known in Australia as ‘bulk billing’ and the advantage for the doctor is that there are no bad debts and no big delays in being paid.

If a doctor wants to charge a patient more than the standard rate set by the Health Insurance Commission, then the patient pays the total of the bill and sends or personally takes the receipt in to the Health Insurance Commission offices. The Health Insurance Commission reimburses the patient the amount set under Medicare for that particular type of service. This means the patient pays only the “gap” between the Medicare rate and what the doctor has billed.

Australia’s Health Insurance System - Provider Numbers

To work as a doctor in Australia, you need to have a Medicare provider number. Provider numbers are issued by the Australian Government through its agency, the Health Insurance Commission.

Changes to Commonwealth legislation have severed the automatic link between medical registration and access to Medicare rebates for overseas-trained doctors and new Australian graduates.

There are different classes of provider numbers for different purposes and you should ask your Australian employer which type of Medicare provider number you require.

A Medicare provider number allows you to:

• raise referrals for specialist services;
• make requests for pathology or diagnostic imaging services;
• attract Medicare rebates for professional services rendered (that is, treat private patients).

However, all doctors with Australian medical registration can obtain a provider number from the Health Insurance Commission that enables them to prescribe pharmaceuticals, order diagnostic tests and refer patients to other doctors.

Overseas-trained doctors wanting to work in private practice, either as general practitioners or specialists, require exemptions from restrictions in the Health Insurance Act 1973 (the Act) to obtain Medicare provider numbers which enable them to provide services which attract Medicare benefits.

Provider Number Restrictions

Australian medical graduates and OTDs who are permanent residents or Australian citizens are required under section 19AA of the Act to obtain recognised postgraduate medical qualifications before they can provide services that attract a Medicare rebate.

In addition, OTDs who were first recognised as medical practitioners under the Act on or after 1 January 1997 are ineligible to provide services that attract Medicare benefits for a period of 10 years (under section 19AB of the Act). This restriction is achieved by applying a 10 year moratorium on provider numbers. This means that you, and your patients, are not able to access Medicare benefits for 10 years from when you were first recognised as a medical practitioner in Australia (if you were registered between 1/1/97 and 18/10/01) or from when permanent residency was granted.

• Exemptions to this moratorium under section 19AB can be granted to OTDs working in districts of workforce shortage by the Commonwealth Department of Health and Ageing. To check if you are affected by this legislation, please contact the Health Insurance Commission on 132 150, or through their web-site at www.hic.gov.au Refer to the information about “Districts of Workforce Shortage” below.

• Also, Overseas Trained Doctors may be eligible for a reduction in the 10 Year Moratorium under the Five Year Program for Overseas Trained Doctors. Refer to the information about the “5 Year Overseas Trained Doctor Program” below.

Temporary Resident Doctors (TRDs)

TRDs usually enter Australia to work in medical positions designated as being 'area of need' by the relevant State or Territory health authority. A list of these health authorities is at Appendix 1B. Alternatively, they may enter as occupational trainees to undertake clinical specialist training.

TRDs are generally granted conditional registration in Australia. These doctors are also subject to supervision by an appropriately qualified Australian medical practitioner. Currently there is no formal assessment of the level of theoretical and clinical skills expected of TRDs.

TRDs cannot access Medicare rebates unless the Minister for Health and Ageing or a delegate of the Minister makes a determination under section 19AB of the Act specifically recognising the doctor for that purpose. This determination does not affect the ability of these doctors to prescribe pharmaceuticals, order diagnostic tests and refer patients to another medical practitioner.

Exemptions under section 19AB of the Act are generally only granted if overseas-trained doctors commit to work in a district of workforce shortage.

A district of workforce shortage can effectively be categorised as one in which the community is considered to have less access to medical professional services than that experienced by the population in general

(a) either because of the remote nature of the community; or
(b) because of lack of supply of services; or
(c) a combination of the two factors.

In making decisions to grant exemptions, the delegate will consider a range of factors. These include:

• Medicare data;
• available workforce data; and
• evidence of unsuccessful attempts to recruit an Australian medical practitioner to positions.

The delegate will also liaise with relevant State or Territory health authorities regarding the 'area of need' classification of positions.

Exemptions granted under section 19AB of the Act are time and location specific and are dependent upon compliance by TRDs with employment arrangements, medical registration requirements and visa restrictions.