Medicare Benefits Schedule - Note AN.0.8

What services are covered?

The Health Insurance Act 1973 stipulates that Medicare benefits are payable for professional services .The professional services coming within the scope of the optometric benefit arrangements are those clinically relevant services ordinarily rendered by the optometrist in relation to a consultation on ocular or vision problems or related procedures.  The Health Insurance Act 1973 defines a 'clinically relevant service' as a service rendered by an optometrist that is generally accepted in the optometrical profession as being necessary for the appropriate treatment of the patient to whom it is rendered. 

From 1 January 2015, optometrists will be free to set their own fees for their professional service. However, the amount specified in the patient's account must be the amount charged for the service specified. The fee may not include a cost of goods or services which are not part of the MBS service specified on the account. A non-clinically relevant service must not be included in the charge for a Medicare item. The non-clinically relevant service must be separately listed on the account and not billed to Medicare. Where it is necessary for the optometrist to seek patient information from Services Australia in order to determine appropriate itemisation of accounts, receipts or bulk-billed claims, the optometrist must ensure that:

(a) the patient is advised of the need to seek the information and the reason the information is required;

(b) the patient's informed consent to the release of information has been obtained; and

(c) the patient's records verify the patient's consent to the release of information. 

Benefits may only be claimed when:

(a)              a service has been performed and a clinical record of the service has been made;

(b)              a significant consultation or examination procedure has been carried out;

(c)              the service has been performed at premises to which the Undertaking relates;

(d)              the service has involved the personal attendance of both the patient and the optometrist; and

(e)              the service is "clinically relevant" (as defined in the Health Insurance Act 1973). 

Where Medicare benefits are not payable

Medicare benefits may not be claimed for attendances for:

(a)              delivery, dispensing, adjustment or repairs of visual aids;

(b)              filling of prescriptions written by other practitioners. 

Benefits are not payable for optometric services associated with:

(a)              cosmetic surgery;

(b)              refractive surgery;

(c)              tests for fitness to undertake sporting, leisure or vocational activities;

(d)              compulsory examinations or tests to obtain any commercial licence (e.g. flying or driving);

(e)              entrance to schools or other educational facilities;

(f)               compulsory examinations for admissions to aged care facilities;

(g)              vision screening. 

Medicare benefits are not payable for services in the following circumstances:

(a)              where the expenses for the service are paid or payable to a recognised (public) hospital;

(b)              an attendance on behalf of teaching institutions on patients of supervised students of optometry;

(c)              where the service is not "clinically relevant" (as defined in the Health Insurance Act 1973). 

Unless the Minister otherwise directs, a benefit is not payable in respect of an optometric service where:

(a)              the service has been rendered by or on behalf of, or under an arrangement with, the Commonwealth, a State or a local governing body or an authority established by a law of the Commonwealth, a law of a State or a law of an internal Territory; or

(b)              the service was rendered in one or more of the following circumstances -

(i)      the employer arranges or requests the consultation

(ii)     the results are provided to the employer by the optometrist

(iii)    the employer requires that the employee have their eyes examined

(iv)   the account for the consultation is sent to the employer

(v) the consultation takes place at the patient's workplace or in a mobile consulting room at the patient's

workplace. 

Services rendered to an optometrist's dependants, employer or practice partner or dependants

A condition of the participating arrangement is that the optometrist agrees not to submit an account or a claim for services rendered to any dependants of the optometrist, to the optometrist's employer or practice partner or any dependants of that employer or partner. 

A 'dependant' person is a spouse or a child.  The following provides definitions of these dependant persons: 

a spouse, in relation to a dependant person means:

(a)           a person who is legally married to, and is not living, on a permanent basis, separately and apart from, that person; and

(b)        a de facto spouse of that person.

a child, in relation to a dependant person means:

(a)           a child under the age of 16 years who is in the custody, care and control of the person or the spouse of    the person; and

(b)        a person who:

(i)  has attained the age of 16 years who is in the custody, care and control of the person of the spouse of the person; or

(ii)  is receiving full time education at a school, college or university; and

(iii) is not being paid a disability support pension under the Social Security Act 1991; and

(iv) is wholly or substantially dependent on the person or on the spouse of the person.

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