All Australian residents and certain categories of visitors to Australia can claim Medicare benefits for services by participating optometrists (optometrists who have signed an agreement to participate in arrangements with the Commonwealth Government). The Health Insurance Act 1973
establishes Medicare and contains legislation covering the major elements of the Medicare program. To be eligible for a Medicare rebate, a patient must not be an admitted public patient of a hospital.
A General Practitioner (GP) referral is not required for a patient to make an appointment to see an optometrist (with the exception of the arrangement with the Better Start for Children with Disability initiative and Helping Children with Autism program). However, to register as an optometrist in Australia, applicants must meet certain requirements as detailed by the Optometry Board of Australia
The Optometry Medicare Benefits Schedule
Information about the Optometry Medicare Benefits Schedule (OMBS) items includes the service length, type, minimum requirements, fees and explanatory notes. This information is located online at MBS Online
Click on the item numbers below to view the current MBS descriptions and explanatory notes.
Claiming a Medicare Rebate
When visiting an optometrist, there are a variety of ways this service can be paid for:
- a patient may be bulk-billed for the services. This means the optometrist will be paid for their services through Medicare and the patient will not have out-of-pocket costs;
- a patient may be charged the Medicare Schedule fee or higher and then can claim the Medicare rebate from the Department of Human Services; and
- a patient may be privately billed for the optometry service if the optometrist is not a participating optometrist or the service provided is not part of the optometric MBS.
In order for a patient to be able to claim a Medicare rebate, all of the following information must be included on an itemised account/receipt from the optometrist:
- patient’s name;
- date of service;
- MBS item number;
- name and provider number (or practice address) of the optometrist; and
- amount charged, total amount paid, and any amount outstanding in relation to the service.
Patients can lodge a claim with the Department of Human Services through their Medicare online account
or by attending a service centre. As well as the Medicare rebate, any additional out-of-pocket costs incurred by the patient with respect to the optometry service count toward the Medicare safety net.
Limitations on Claiming a Rebate
Medicare only pays benefits for services provided by ‘participating’ optometrists who have signed a Common Form of Undertaking for Participating Optometrists with the Australian Government. From 1 January 2015, participating optometrists are able to claim more than the MBS Schedule fee for services covered under Medicare. If the fee is greater than the Medicare benefit, optometrists participating in the scheme are to inform the patient of the Medicare benefit payable for the item, at the time of the consultation and that the additional fee will not attract benefits.
‘Participating’ optometrists agree that charges for appliances shall not include any amount related to consultation procedures for which benefits are payable.