Medicare, Gaps and Safety Net (Part 3) - How much can I get back from Medicare?

With the recent discussion of paying $7 to see a General Practitioner (GP) in the budget, it seems it will be the demise of Bulk Billing.

But what exactly is Bulk Billing? When do we pay extra and how much do we get back from Medicare? What does the safety net mean? And what's the difference between scheduled fee and Australian Medical Association recommended fees? What's the Medical Levy Surcharge?

The system is indeed very complex. I hope this series about Medicare would help explain how it all works. In this post, I will focus on how much you will get back from Medicare if your doctor does not bulk bill.

When you see your doctor, each service provided which falls under the Medicare Benefits Schedule (MBS) number 23. There are different item numbers depending on the following factors:
is billed using a defined item number set out by the Schedule. This means for instance if you go to see your GP at his or her practice for a standard appointment of less than 20 minutes, you will be billed under item

• Who provided the care. For example, GP, different specialist, and different allied health professionals would fall into different sets of item numbers.
• How long was the appointment for. For example, a 15 minute appointment and a 30 minute appointment would have different item numbers.
• Where the care was provided. For example, if the service was provided at a doctor's practice versus if the a home visit or in a nursing home, would have different item numbers.
• If this appointment the first appointment or a follow up appointment.

This item number does not define what your doctor can charge you. Rather, it defines what you can get back. Each item on the schedule is given a benefit dollar amount, I will refer this as "scheduled fee". Excluding the safety net, how much you can get back depends on the following.

• If this item is a visit to your GP, the benefit is 100% of scheduled fees.
• If this is a visit to any other outpatient service, like to see a specialist or psychologist, the benefit is 85% of scheduled fees.
• If this item is for fee is for your stay in hospital as a private patient (even in a public hospital), the benefit is 75% of scheduled fee.

This is an example of a GP visit. (Assuming you have not reached the safety net.)

If you see your GP for a visit less than 20 minutes, this will fall under item number 23. Let's say he charges you $70. The current scheduled fee is $37.05 (as of August 2014). You will get back 100% of the scheduled fees - this means you will get back $37.05. Your out-of-pocket expense will be $32.95.

This is an example of a follow up visit to a psychiatrist. (Assuming you have not reached the safety net.)

If you see your psychiatrist who was referred to by your GP, and this appointment was 35 minutes long, this will fall under item number 304. Let's say he charges you $200. The current scheduled fee is $133.10 (as of August 2014). You will get back 85% of the scheduled fees - this means you will get back $113.15. Your out-of-pocket expense will be $86.95.

As you can see, if you are ill, this out of pocket expense can add up quite quickly. The government has put in place the Medicare Safety Net to minimise expenses once you have paid out of pocket to a certain level. I will elaborate more about this on the next post.

Reference:

MBS online

Related Posts:
Medicare, Gaps and Safety Net (Part 1) - Bulk billing
Medicare, Gaps, Safety Net (Part 2) - How do I make a Medicare Claim?