Medicare

admitted patient: A patient who undergoes a hospital’s formal admission process to receive treatment. This treatment can occur in hospital and/or in the person’s home (for hospital-in-the-home patients). Also known as inpatient.

allied health: A range of services provided by accredited health practitioners with specialised expertise in preventing, diagnosing and treating a range of conditions and illnesses. The practitioners have autonomy of practice, a defined scope of practice, a regulatory mechanism and a national organisation with clearly defined entrance criteria. Examples include psychologists, optometrists and physiotherapists.

allied health practitioner: A health practitioner who is not a medical practitioner, nurse, or dentist. Allied health practitioners include (but are not limited to) Aboriginal and Torres Strait Islander health practitioners, audiologists, chiropractors, dieticians, occupational therapists, optometrists, osteopaths, physiotherapists, podiatrists, psychologists, and speech pathologists.

anaesthetic: A drug or agent that causes a complete or partial loss of sensation by stopping nerve signals from reaching the brain. This prevents pain and discomfort during a diagnostic or therapeutic procedure.     

attendance: A patient-doctor encounter, such as a visit, consultation and attendance (including telehealth via telephone or video conferencing).

bulk billing: The process whereby a patient assigns his/her entitlement to a Medicare benefit to the treating practitioner, who in turn submits the claim directly to Services Australia. The practitioner cannot charge a co-payment. Also known as direct billing.

bulk billing incentive: An additional payment for a service, rather than a separate service. Bulk billing incentive items are ‘top-up’ items that provide supplementary benefits to items to which they relate. All top-up items are excluded from the count of services but are included in the amount of benefits paid.   

co-payment: An amount the patient pays towards the cost of a funded service.

diagnostic imaging: The production of diagnostic images; for example, computed tomography, magnetic resonance imaging, X-rays, ultrasound, and nuclear medicine scans.

general practice: A medical speciality of study on diseases affecting the body. It does not specialise in a particular disease or organ.  

general practitioner (GP): A medical practitioner who is a specialist qualified to provide primary comprehensive and continuing care for patients regardless of age or health condition, in the community. Unlike other specialties that are specialised in a particular discipline of medicine.

General practitioners include Fellows of the Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM), vocationally registered general practitioners and medical practitioners undertaking an approved general practice placement in a training program. 

general practitioner (GP) attendance: A non-referred patient-doctor encounter with a GP.

hospital service: For the purposes of the Medicare Benefits Schedule, hospital services refer to private inpatients involving hospital treatment or hospital substitute treatment. Other services provided in a hospital setting (for example, private outpatient services) are not regarded as hospital services.

hospital substitute treatment: Hospital-in-the-home treatment.

medical practitioner: Under the Health Practitioner Regulation National Law, a medical practitioner is a person who holds registration with the Medical Board of Australia.

Medicare: A universal health care system for all Australians and some overseas visitors. Medicare covers the full cost of treatment (including accommodation) for public patients in hospitals, and partially or fully covers the cost of many health services and medications. Medicare is often used solely to mean health services included in the Medicare Benefits Schedule.

Medicare benefit: Subsidies or rebates paid to patients under Medicare. Medicare benefits are calculated based on the Schedule fees, and depend on the type of service and where the service is provided. The relevant rates of benefits are:

• 100% of the Schedule fee for GP attendances rendered out-of-hospital
• 85% of the Schedule fee for other out-of-hospital services
• 75% of the Schedule fee for in-hospital services for private patients.

Also known as Medicare subsidy or Medicare rebate.

Medicare Benefits Schedule (MBS): A listing of medical and allied health services subsidised by the Australian Government. The MBS is part of the wider Medicare Benefits Scheme. 

Medicare Benefits Scheme: The Medicare Benefits Scheme is part of Australia’s public health insurance scheme. Through the Scheme, the Australian Government subsidises the costs of a wide range of health services.

Medicare safety nets: Medicare safety nets provide higher benefits for individuals and registered families (including couples), who face high out-of-pocket expenses for non-hospital services. When the out-of-pocket expenses exceed a threshold, further non-hospital services attract higher benefits for the remainder of the calendar year. There are 2 Medicare safety nets. 

Under the original Medicare safety net, gap payments between the Medicare benefit and the Schedule fee count towards the safety net threshold.

Under the extended Medicare safety net, out-of-pocket payments between the Medicare benefit and the provider fee count towards safety net thresholds (a general threshold and a lower threshold). The lower threshold applies to individuals or registered families, who are concessional or qualify for Family Tax Benefit Part A.

non-admitted patient: A patient who has not undergone a hospital’s formal admission process. Also known as outpatient. 

nurse practitioner: A registered nurse with experience, expertise and authority to diagnose and treat people with a variety of acute or chronic health conditions.

obstetrics: The branch of medicine and surgery concerned with childbirth and midwifery.

operation: A physical medical intervention, often called a surgery, to treat or investigate a disease or injury that is listed in the surgical operations section of the Medicare Benefits Schedule, excluding specific procedures frequently done by non-surgical clinicians.

optometry: The practice of primary eye care, including testing for visual acuity and prescribing treatments for eye disorders.

other medical practitioner: In the context of GP attendances, other medical practitioners include specialists and consultant physicians working in a general practice setting in their capacity as medical practitioners who are not vocationally registered GPs, and suitably qualified health practitioners (including registered nurses). 

out-of-hospital service: Services delivered to patients who are not admitted patients. Also known as non-hospital service.

out-of-pocket cost: The total cost incurred by an individual for a health service over and above any rebates from Medicare. Supplementary benefits paid by health funds, for privately insured episodes of hospital treatment or hospital substitute treatment are not captured in Medicare claim records and are not taken into account in computing out-of-pocket cost.

pathology: A general term for the study of disease, but often used more specifically to describe diagnostic services that examine specimens, such as samples of blood or tissue.

patient billing: Patients are charged a fee for a service rendered by their provider.

practice nurse: A registered or enrolled nurse who assists GPs or medical practitioners delivering services to patients. 

private hospital: A privately (non-government) owned and operated institution, catering for patients who are treated by a doctor of their own choice. Patients are charged fees for accommodation and other services provided by the hospital and by relevant medical and allied health practitioners. 

private patient: A person admitted to a private hospital, or a person admitted to a public hospital who decides to choose the doctor(s) who will treat them or to have private ward accommodation. This means they will be charged for medical services, food and accommodation.

public hospital: A hospital controlled by a state or territory health authority. Public hospitals offer free diagnostic services, treatment, care and accommodation to all eligible patients.

public patient: A patient admitted to a public hospital (or provided with care by a private hospital on behalf of a public hospital) who has agreed to be treated by doctors of the hospital’s choice and to accept shared ward accommodation. This means that the patient is treated at no charge.

radiation therapy: The treatment of disease by means of ionizing radiation.

Schedule fee: A fee for each service on the Medicare Benefits Schedule set by the Australian Government to calculate a Medicare benefit. It may differ from the health practitioner’s actual fee charged.   

specialist: A fully-qualified physician who has specialised and works primarily in areas other than general practice. 

specialist attendance: A specialist attendance usually requires a referral from a GP. It is a referred patient-doctor encounter with a medical practitioner who has been recognised as a specialist or consultant physician.

specialist service: Services that support people with specific or complex health conditions and issues, who are generally referred by primary health care providers. They are often described as secondary health care services. In many cases, a formal referral is required for an individual to be able to access the recommended specialist service.

telehealth: Health services delivered using information and communication technologies, such as videoconferencing or through other communication technologies.

unreferred service: A service provided to a person by, or under the supervision of, a medical practitioner – being a service that has not been referred to that practitioner by another medical practitioner or person with referring rights. These are services that are classified as primary health care.