Medicare information for health professionals

Important information for accessing Medicare as a health professional.

National health care

The national health care funding system gives eligible Australian residents access to health care at an affordable or no cost.

The Australian health care system includes a mixture of public and private sector health services.

The Australian Government's health funding includes 3 major national subsidy schemes:

  • Medicare, Australia's universal health care program
  • Pharmaceutical Benefits Scheme (PBS)
  • Australian Government Rebate on private health insurance

Medicare and PBS cover eligible Australian residents and subsidise their payments for private medical services and a high proportion of prescription medicine.

Australian Government funding of the rebate on private health insurance supports people's choice to get and keep private health insurance.

Medicare

Medicare provides access to:

  • free or subsidised treatment by health professionals such as
    • doctors
    • specialists
    • optometrists
    • dentists, and
    • other allied health professionals, in special circumstances
  • free treatment and accommodation as a public Medicare patient in a public hospital

Medicare also provides access to 75% of the Medicare Schedule fee for services and procedures if you are a private patient in a public or private hospital. However, this does not include hospital accommodation and items such as theatre fees and medicines.

Federal, state or territory and local government responsibilities

The Australian Government has the primary role of developing national policies, regulations and funding.

The Australian Government and state and territory governments mutually fund Australia’s public hospital system.

State, territory, and local governments are responsible for the delivery and management of public health services and for maintaining direct relationships with most health care providers. This includes the regulation of health professionals and private hospitals.

How we work with the Department of Health

We work in partnership with the Department of Health (Health) to achieve the Australian Government's health policy objectives.

We make payments for services provided by eligible health professionals under Medicare, the PBS and other programs, such as the Australian Childhood Immunisation Register.

Health is responsible for the policy development of the Medicare program and the Medicare Benefits Schedule (MBS).

We are responsible for administering the Medicare program on behalf of Health. This includes registration of details for health professionals eligible to have Medicare benefits paid for their services.

Working in Australia

To work as a doctor in Australia, you must have current registration in the state or territory in which you intend to practise. You may also need to have a Medicare provider number, which allows you and your patients to claim Medicare benefits for the services you provide.

A Medicare provider number can allow you to:

  • raise referrals for specialist services
  • make requests for pathology or diagnostic imaging services

If you satisfy the legislative requirements a provider number can be used to accrue Medicare benefits for professional services rendered, such as treating private patients.

A Medicare provider number does not automatically allow you to get Medicare benefits for your services.

Eligibility to access Medicare benefits is determined by the Health Insurance Act 1973 (the Act) and related regulations. In particular, the requirements of sections 19AA and 19AB of the Act must be satisfied before access to Medicare benefits can be granted. The Act can be found on the ComLaw website.

A Medicare provider number uniquely identifies both you and the place you work.

Medicare provider number restrictions

Overseas trained doctors (OTDs) are subject to Medicare provider number restrictions if they want to treat private patients. These restrictions affect where an OTD can work in Australia.

If you work in a District of Workforce Shortage you may be able to get exemption from these restrictions.

We issue Medicare provider numbers after an OTD has been offered a medical job in Australia. The Application for an initial Medicare provider number for a medical practitioner form (HW019) is available on our website.

Specialists

Specialists requiring access to Medicare benefits that attract a higher specialist payment need to apply for recognition as a specialist for Medicare billing purposes.

Page last updated: 5 April 2016

This information was printed Tuesday 27 September 2016 from humanservices.gov.au/health-professionals/subjects/medicare-information-health-professionals It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.