Guidance for Practitioners on when to claim 75 / 85 / 100% benefits under Medicare for health professionals – December 2021

Guidance on when to claim hospital treatment benefits (75%)

The following guidance is aimed at helping practitioners, billing agents and other parties involved in Medicare billing to understand when hospital treatment (75%) benefits apply to services claimed under the Medicare Benefits Schedule (MBS), and by extension, when 85% and 100% benefits apply.  These benefits are all paid as proportions of the Medicare Schedule Fee for the relevant item set out in the MBS.  Guidance has also been included for consumers.

For privately funded services, the intent of the legislative framework as set out in the Health Insurance Act 1973 (HIA) and the Private Health Insurance Act 2007 (PHI Act)  is for the Government to pay 75% of the MBS fee for any ‘hospital treatment’ (as defined in the PHI Act) ) and for the patient’s private health insurance, if the patient has insurance and the insurance covers the medical service, to pay at least the remaining 25% of the MBS fee.  If the patient does not have private health insurance, or the patient’s private health insurance does not cover that service, then the patient themselves can be expected to cover the gap, if the provider chooses to charge more than the 75%.

‘Hospital treatment’ is defined in Section 121-5 of the Act and includes any treatment (including goods or services) intended to manage a disease, injury or condition, provided at a hospital (or with the direct involvement of the hospital).

Some MBS items are specifically excluded from the definition of hospital treatment unless a certification under section 7(2) of the Private Health Insurance (Benefit Requirements) Rules 2011 (Benefit Rules) is provided (a Type C certificate).  Part 3, Schedule 3 of the Benefit Rules provides a list of these excluded MBS numbers. 

Guidance for practitioners and billing agents

The following can be used to determine when to bill Medicare for an item as ‘hospital treatment’*:

• Interventional services** (e.g. surgeries, interventional diagnostic services such as colonoscopies) done at hospitals are generally hospital treatment so attract 75% benefits.  This includes services provided to admitted patients, or patients in the outpatient (or in a ‘day-hospital’) setting.
  • Interventional services, or other services provided to private patients in emergency departments do not, under legislation, attract 75% benefits
  • The decision when to provide a service at, or outside of, a hospital and whether it requires direct involvement of a hospital is a matter for the clinical judgement of the practitioner.  Some services may be clinically appropriate to provide outside of a hospital (for example, cryotherapy or minor skin surgeries) with no involvement of a hospital and can attract an 85%[2] or 100% benefit.  If a service attracts an 85%[3] or 100% MBS benefit, there will be no requirement for a private health insurance contribution of at least 25% of the Schedule fee to be paid toward the cost of the service.
• Most consultations, pathology** and diagnostic imaging** services are listed Type C procedures*** and therefore default to 85% or 100% benefits.  These services can attract 75% benefit if they are certified, for example:
  • the hospital facilities were required for the service; or
  • the imaging or testing was done in relation to a hospital-in-the-home service; and
  • This will also mean the patient’s private health insurance must contribute at least 25% of the Schedule fee toward the cost of the service.
•  Other services attract an 85% or 100% benefit  (the latter being for general practitioner services) as appropriate.  Temporary specialist in-patient telehealth items, introduced on a time-limited basis on 15 September 2021, attract an 85% rebate only.[4]

 

 

Hospital treatment and benefits– further information and exceptions[5]

Hospital treatment is treatment intended to manage a disease injury or condition, that is provided by a person authorised by a hospital to do so or by a person under the management or control of a hospital/hospital administrator. It is treatment that is being provided to a person at a hospital or is being provided or arranged with the direct involvement of a hospital. This includes treatment provided to day-hospital patients and outpatients (excluding Type C procedures, where not certified). It does not include treatment done in private rooms that are co-located, but unaffiliated with a hospital.

Hospital treatment does not include treatment of a private patient in a hospital emergency department, type C procedures that have not been certified, ongoing chronic disease management or treatment for people who are not ‘patients’ under legislation - as these patients are not eligible for Medicare benefits.