Medicare provides eligible people access to medical, optometry and hospital care and other allied health services.

In 2018–19, 25.6 million people were enrolled in Medicare and $24.4 billion was paid in benefits. The percentage of claims made digitally continues to grow, with 98.6 per cent of Medicare services claimed digitally in 2018–19. Approximately 76 per cent of all health practices lodge 100 per cent of their Medicare claims digitally at their practice.

During the year the department made technology enhancements to promote digital transactions.

Medicare eligibility

To be eligible for services under Medicare a person must be one of the following:

• an Australian citizen residing in Australia
• a permanent resident or a New Zealand citizen residing in Australia
• an applicant for permanent residency, meeting certain criteria—restrictions and other requirements apply to people who have applied for a parent visa
• a Resident Return visa holder residing in Australia
• a resident or citizen of a country with which Australia has a reciprocal health care agreement—only for medically necessary treatment while visiting Australia (a person must meet the specific eligibility requirements set out in the agreement)
• covered by a ministerial order.

Table 11: Medicare enrolments

Connecting Australians to the health payments and services they need

Australians told us they need to access health information, payments and services more easily—and we listened.

In 2018–19 we set out to overhaul the presentation of Medicare information on our website to better suit our customers’ needs. We created a new information structure with a better search function and a new visual design, all written in plain English that people can easily understand.

We checked in with customers regularly throughout the 10-month redevelopment process, using task-based scenarios to see how they navigate, locate and use our information to complete Medicare activities.

The result is a website that cuts both effort and time.

We’ve seen a 14.6 per cent decrease in the overall number of Medicare sessions on the website, as well as 11 per cent less circular navigation, meaning more people are finding the information they need the first time. We’ve also seen a dramatic improvement in people’s ability to find out if they’re eligible for a Medicare card—the task completion rate increased from 15 per cent to 71 per cent on mobile devices and from 32 per cent to 74 per cent on desktops.

Medicare Entitlement Statements

People who do not meet the eligibility criteria for Medicare may apply to be exempt from paying the Medicare levy. If the application is approved, the department issues a Medicare Entitlement Statement. When a person lodges their income tax return and applies for a Medicare levy exemption, the Australian Taxation Office (ATO) requires them to acknowledge that they have been issued with a Medicare Entitlement Statement.

Table 12: Medicare Entitlement Statements

Medicare Safety Net

The Medicare Safety Net provides an additional Medicare benefit to eligible individuals, couples and families who have high out‑of‑hospital medical expenses.

When the total out‑of‑pocket costs a customer pays reaches a certain threshold, the customer can receive higher Medicare benefits. Out‑of‑pocket costs are the difference between the doctor’s charge and the Medicare benefit paid.

The Medicare Safety Net has two levels:

• the Original Medicare Safety Net
• the Extended Medicare Safety Net.

The Original Medicare Safety Net threshold for the 2019 calendar year is $470 and applies to all Medicare cardholders. Under this threshold, the gap amount that consumers pay counts towards the threshold. The gap amount that consumers pay is the difference between the Medicare Benefits Schedule (MBS) fee and the Medicare benefit paid.

The Extended Medicare Safety Net has two threshold levels for the 2019 calendar year:

• $680.70 for Commonwealth concession cardholders and Family Tax Benefit Part A recipients
• a general threshold of $2,133 for all other Medicare cardholders (individuals and registered families).

Only out‑of‑pocket costs count toward the thresholds.

Medicare claiming

Health professionals can ‘bulk bill’ their patients. This means that the patient agrees to have their Medicare benefit paid directly to the health professional. The health professional can claim the Medicare benefit directly from the department as full payment for the service.

If a health professional charges the patient a fee (that is, the patient is not bulk billed), there are three ways to claim the Medicare benefit:

• The claimant can pay the account directly to the health professional. Then, if the health professional or practice offers digital claiming, practice staff can lodge the claim digitally with the department, with most claims paid into the claimant’s bank account within 48 hours.
• The claimant can pay the account and then claim the Medicare benefit from the department. They can claim using the Express Plus Medicare mobile app; through their Medicare online account via myGov; or by mail, by phone or in person at a Service Centre. Claims lodged through Medicare online accounts or the Express Plus Medicare mobile app are generally processed within seven days of receipt. Paper‑based claims lodged through the mail or at a Service Centre take longer to process than claims that are digitally submitted.
• The claimant can lodge an unpaid account with the department and receive a cheque payable in the health professional’s name. The claimant then gives the cheque to the health professional and pays any outstanding balance.

Where a patient has received in‑hospital services, Medicare claims can be made through simplified billing arrangements. Simplified billing streamlines the way patients pay their bills and claim benefits from the department and their private health insurer. Simplified billing claims can be lodged by hospitals, billing agents, providers and day surgeries with the department and private health insurers. This is done through the Electronic Claim Lodgement Information Processing Service Environment (ECLIPSE), through Secure File Transfer Protocol (SFTP) systems, or manually.

Table 13: Medicare services and benefits by claim type

Table 14: Medicare services by payment type

Table 15: Volumes of services transmitted digitally

Health professionals under Medicare

Where an eligible health professional provides services covered by Medicare, they must be allocated a specific Medicare provider number for each practice location. A Medicare provider number uniquely identifies the health professional and the location from which a service is delivered. The provider number allows the health professional to prescribe, refer or request health services for patients and claim benefits under the MBS and on behalf of DVA. A health professional providing health services at multiple locations must apply for and be issued with a provider number specific to each location.

In 2018–19, the department issued 183,998 Medicare provider numbers.

Practices that have diagnostic imaging services, including radiation oncology, must be registered with the department and have a Location Specific Practice Number to claim Medicare benefits.

The number of diagnostic imaging practices that register with the department continues to increase each year. In 2018–19, 5,221 diagnostic imaging practices were registered with the department.

Health professionals who provide pathology services must have departmental approval to claim Medicare benefits. In 2018–19, there were 98 Approved Pathology Authorities, 490 Approved Pathology Practitioners, 728 Accredited Pathology Laboratories and 3,722 Approved Collection Centres registered as active services with the department.

Table 16: Health professionals under Medicare

Medicare Compensation Recovery

Medicare Compensation Recovery aims to recover any Medicare benefits, nursing home benefits or residential care or home care government subsidies paid to a claimant as a result of their compensable injury or illness.

When a person receives a lump sum compensation payment of more than $5,000 for an injury or illness, they may have to repay moneys that the government paid to them for treatment of their injury or illness. This amount is repaid by the insurer from the compensation sum before the residual amount is paid to the claimant.

In 2017–18 and 2018–19, the number of cases finalised was lower than in 2016–17. The number of cases finalised in the 2016–17 financial year was higher as a result of the closure of a large number of discontinued older cases that did not have an associated recovery amount. The amounts recovered in 2017–18 and 2018–19 were higher as a result of resolving large numbers of older complex cases.

Table 17: Compensation recovery