A Medicare benefit is payable when a medical service is provided to an eligible person by an eligible health professional in Australia.
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
- meet eligibility requirements set out in the Health Insurance Act 1973
Key eligibility rules are outlined below.
Section 19AA of the Act has a quality assurance purpose and applies to all health professionals. To qualify for a Medicare provider number, in broad terms, section 19AA states you must get 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 apply for vocational recognition or Fellowship with the Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM) you need to complete one of the following forms:
- Application for certification of eligibility for Vocational Registration of General Practitioners
- Application for recognition – Fellow of the Royal Australian College of General Practitioners, or
- Application for recognition – Fellow of the Australian College of Rural and Remote Medicine
To satisfy section 19AA and obtain a Medicare provider number, you must be:
- a recognised specialist, consultant physician or GP
- in an approved placement under section 3GA of the Act
- 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
You must get such a placement under a recognised workforce or training program to satisfy section 19AA.
These programs must be recognised for the purposes of section 3GA of the Act. 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
A health professional may also remove themselves from the Vocational Register or from one of the Recognised Fellows List. To request this you need to complete one of the following forms:
- Request to remove your name from the Vocational Register of General Practitioners
- Request to remove your name from a Recognised Fellows List
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 get a section 19AB exemption before you can be granted a provider number.
Read more about overseas trained doctors and foreign graduates.
If you don’t meet the requirements
If you’re a qualified and registered health professional but don’t satisfy the requirements outlined above you may still practise medicine. However, the services you provide won’t be eligible for Medicare benefits.
It’s an offence under section 19CC of the Act to provide a service without first informing a patient if a Medicare benefit isn’t payable. This happens when the service isn’t listed in the MBS or the practitioner isn’t eligible for Medicare.