Medicare benefits for health professionals

A Medicare benefit is payable when a medical service is provided to an eligible person by an eligible health professional in Australia.

Eligibility

The Medicare benefit that is payable is subject to relevant rules and guidelines.

To be able to provide a medical service that will attract a Medicare benefit, a health professional:

  • must hold current registration with the Medical Board of Australia, and
  • must meet eligibility requirements set out in the Health Insurance Act 1973

Key eligibility rules are outlined below.

Vocational recognition

Section 19AA of the Act serves a quality assurance purpose and applies to all health professionals. To qualify for a Medicare provider number, in broad terms, section 19AA states health professionals must obtain vocational recognition as:

  • a general practitioner (GP)
  • a specialist, or
  • a consultant physician

A health professional is considered vocationally recognised in their specialist field of medicine when they become a Fellow of the relevant Australian or Australasian specialist college.

To satisfy section 19AA and obtain a Medicare provider number, a health professional must be:

  • a recognised specialist, consultant physician or GP
  • in an approved placement under section 3GA of the Act
  • a health professional first registered before 1 November 1996 ­– some exclusions apply, further information can be found on the ComLaw website, or
  • a temporary resident doctor with an exemption under section 19AB of the Act, working in accordance with that exemption

Health professionals must obtain such a placement under a recognised workforce or training programme. You are subject to having an approved programme placement in order to satisfy section 19AA.

These programs must be recognised for the purposes of section 3GA of the Act. The recognised 3GA programs are:

  • Australian General Practice Training Program – Department of Health (Health)
  • Approved Medical Deputising Service Program – Health
  • Temporary Resident Other Medical Practitioner Program – Health
  • Approved Private Emergency Department Program – Health
  • Australasian College of Sports Physicians Training Program – Australasian College of Sports Physicians
  • Queensland Country Relieving Program – Queensland Department of Health
  • Special Approved Placements Program – Health
  • Approved Placements for Sports Physicians Program – Health
  • Specialist College Trainee programs – relevant Australian Specialist Colleges
  • Remote Vocational Training Scheme – Remote Vocational Training Scheme Limited
  • Rural Locum Relief Program – Rural Workforce Agencies in each state and territory

Overseas trained doctors and foreign graduates

Section 19AB of the Act applies to overseas trained doctors (OTDs) and foreign graduates of an accredited medical school (FGAMS). A health professional who meets the definition of an OTD or FGAMS must obtain a section 19AB exemption before they can be granted a provider number.

Read more about overseas trained doctors and foreign graduates.

If you don’t meet the requirements

If you are a qualified and registered health professional but do not satisfy the requirements outlined above you may still practise medicine. However, the services you provide will not be eligible for Medicare benefits.

It is an offence under section 19CC of the Act to provide a service without first informing a patient if a Medicare benefit is not payable, such as when the service is not listed in the MBS or the practitioner is not eligible for Medicare.

Page last updated: 7 April 2016