What does Medicare Cover?
Rule one – You have to have a valid Medicare card
Rule two – Not everything is covered
Rule Three – GP and Specialists have some different rules. I might leave that for a different blog. This one if just about GPs.
Rule Four – You have to be alive. You can claim a rebate if I visited and determined you dead, but then that’s when the rebates end!
Rule Five – When you talk with your GP, it is not always safe you assume there is a Medicare rebate for this visit.
Enough of the rules….
It may be easier to list what Medicare doesn’t cover. And the list is longer than you may think. I have used the most up to date Medicare Benefits Schedule Book Category 8 as the basis of this information.
Firstly, unless there are really special occasions (like a case conference) you need to have a face-to face consultation to access a Medicare rebate.
Telephone consultations, Facebook posts and Skype or FaceTime chats do not have a rebate.
There is no rebate for repeat prescriptions when the patient doesn’t consult with their GP. Many prescriptions used to treat chronic illness last 6 months. If you have a chronic health problem a six month check up may be sensible. After all you service your car regularly.
Non-therapeutic cosmetic surgery doesn’t attract a rebate. So, that annoying mole on your nose, unless it looks like a skin cancer doesn’t earn a rebate when it is removed. Likewise, Botox for wrinkles doesn’t have a rebate.
Euthanasia and any service directly related to the procedure doesn’t have a rebate. This one surprised me given that until Victoria’s law is enacted, euthanasia is not legal. This was also listed in the 2014 version of the Medicare Book, so maybe it was written in that brief time euthanasia was legal in the NT. However, for counselling about euthanasia will attract a rebate.
Medicare rebates are not payable for a compensable injury or illness for which the patient’s insurer or compensation agency has accepted liability. However, whilst the process is pending, a rebate is available. Medicare then seeks reimbursement from the insurer.
Medicare benefits are not available for a medical examination for the purposes of life insurance, superannuation, a provident account scheme, or admission to membership of a friendly society. This also applies to Likewise pre-employment and workplace medicals, and health screening (although there are some exceptions).
Medicare lists a number of specific treatment that it doesn’t rebate for. I’ll list these, although many are things that a GP is unlikely to do. Other’s are areas of controversy in the world of evidence based medicine. Specifically these are
- chelation therapy other than for the treatment of heavy-metal poisoning
- the injection of human chorionic gonadotrophin in the management of obesity
- the use of hyperbaric oxygen therapy in the treatment of multiple sclerosis
- the removal of tattoos
- the transplantation of a thoracic or abdominal organ, other than a kidney, or of a part of an organ of that kind
- the removal from a cadaver of kidneys for transplantation
- the administration of microwave (UHF radio wave) cancer therapy, including the intravenous injection of drugs used in the therapy
- cannulation and/or catheterisation of surgical sites associated with pain pumps for post-operative pain management
- filling or re-filling of drug reservoirs of ambulatory pain pumps for post-operative pain management
- injection of blood or a blood product that is autologous.
- endoluminal gastroplication, for the treatment of gastro-oesophageal reflux disease
- gamma knife surgery
- intradiscal electro thermal arthroplasty
- intravascular ultrasound (except where used in conjunction with intravascular brachytherapy)
- intra-articular viscosupplementation, for the treatment of osteoarthritis of the knee
- low intensity ultrasound treatment, for the acceleration of bone fracture healing, using a bone growth stimulator
- lung volume reduction surgery, for advanced emphysema
- photodynamic therapy, for skin and mucosal cancer
- placement of artificial bowel sphincters, in the management of faecal incontinence
- selective internal radiation therapy for any condition other than hepatic metastases that are secondary to colorectal cancer
- specific mass measurement of bone alkaline phosphatase
- transmyocardial laser revascularisation
- vertebral axial decompression therapy, for chronic back pain
- autologous chondrocyte implantation and matrix-induced autologous chondrocyte implantation
Although some screening programmes like breast cancer and cervical cancer screening are allowed a Medicare rebate, most health screening services are not covered. Medicare lists the following examples where there is no rebate available.
- multiphasic health screening
- testing of fitness to undergo physical training program, vocational activities or weight reduction programs
- compulsory examinations and tests to obtain a flying, commercial driving or other licence
- entrance to schools and other educational facilities
- for the purposes of legal proceedings
- compulsory examinations for admission to aged persons’ accommodation
Specifically, Medicare does recognise the following kinds of health screening
“A medical examination or test on a symptomless patient by that patient’s own medical practitioner in the course of normal medical practice, to ensure the patient receives any medical advice or treatment necessary to maintain their state of health. Benefits would be payable for the attendance and tests which are considered reasonably necessary
according to patients individual circumstances (such as age, physical condition, past personal and family history).”
Medicare then uses some examples which at the bread and butter of primary care in general practice.
- cervical cancer screening under the National Cervical Screening Program
- blood lipid estimation where a person has a family history of lipid disorder
- pathology service requested by the National Heart Foundation of Australia, Risk Evaluation Service
- age or health related medical examinations to obtain or renew a license to drive a private motor vehicle. Commercial license medical examination is not rebatable, although if you were unemployed my interpretation is it would be.
- medical examination of, and/or blood collection from persons occupationally exposed to sexual transmission of disease
- medical examination for a person as a prerequisite of that person becoming eligible to foster a child or children
- medical examination being a requisite for Social Security benefits or allowances
- medical or optometrical examination provided to a person who is an unemployed person as the request of a prospective employer
Medicare rebates are not paid when a doctor treats his or her practice partner, spouse or children. Medicare also excludes the practice partner’s dependents too.