Medicare Benefits Schedule - Note CN.0.1

CN.0.1 Schedule Fees and Medicare Benefits

Medicare benefits are based on fees determined for each Schedule service. The fee is referred to in these notes as the "Schedule fee". The fee for any item listed in the Schedule is that which is regarded as being reasonable on average for that service having regard to usual and reasonable variations in the time involved in performing the service on different occasions and to reasonable ranges of complexity and technical difficulty encountered. 

The Schedule fee and Medicare benefit levels for the medical services contained in the Schedule are located with the item descriptions.  Where appropriate, the calculated benefit has been rounded to the nearest higher 5 cents.  However, in no circumstances will the Medicare benefit payable exceed the fee actually charged. 

There are presently two levels of Medicare benefit payable for cleft lip and cleft palate services:

(a)              75% of the Schedule fee:

­ for professional services rendered to a patient as part of an episode of hospital treatment (other than public patients).  Medical practitioners must indicate on their accounts if a medical service is rendered in these circumstances by placing an asterisk '*' or the letter 'H' directly after an item number where used; or a description of the professional service and an indication the service was rendered as an episode of hospital treatment (for example, 'in hospital', 'hospital outpatient service', 'admitted' or 'in patient'). Certain services are not generally considered hospital treatments - see GN.1.2;

­ for professional services rendered as part of an episode of hospital-substitute treatment, and the patient who receives the treatment chooses to receive a benefit from a private health insurer.  Medical practitioners must indicate on their accounts if a medical service is rendered in these circumstances by placing the words 'hospital-substitute treatment' directly after an item number where used; or a description of the professional service, preceded by the words 'hospital-substitute treatment'.

(b)              85% of the Schedule fee, or the Schedule fee less $98.70 (indexed annually), whichever is the greater, for all other professional services. 

It should be noted that the Health Insurance Act 1973 makes provision for private medical insurance to cover the "patient gap" (ie, the difference between the Medicare benefit and the Schedule fee) for services attracting benefit at the 75% level. Patients may insure with private health insurance organisations for the gap between the 75% Medicare benefit and the Schedule fee or for amounts in excess of the Schedule fee where the patient has an agreement with their health fund.

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