These services must be provided by a ‘participating’ optometrist (one who has entered an agreement with the Australian Government) for the patient to receive a Medicare rebate / payment. Optometric services that are not listed on the MBS and/or provided by a non-participating optometrist are not eligible for a Medicare rebate and may attract a private fee.
For the purpose of this overview, a private service is a service provided by an optometrist for which there is no Medicare rebate. In this situation an optometrist is able to charge a private fee for this service as the service is not paid for by Medicare. The fee charged will vary depending on the type of service provided.
In circumstances where there is no MBS item, the fee charged for a service is a matter between the optometrist and the patient. A patient should expect that the optometrists will:
- advise the patient that no Medicare item exists and that they intend to charge a private fee; and
- itemise receipts to properly reflect Medicare fee/s and private fees.
The Australian Government has determined that Medicare benefits do not cover the following attendances:
- delivery, dispensing, adjustment or repairs of visual aids such as spectacles or contact lenses. See information on the Eye Health Schemes and the exception for gold and white Repatriation Health Card holders; and
- filling of prescriptions written by other practitioners.
Benefits are not payable for optometric services associated with:
- cosmetic surgery;
- refractive surgery;
- tests for fitness to undertake sporting, leisure or vocational activities;
- compulsory examinations or tests to obtain any commercial licence (e.g. flying or driving);
- entrance to schools or other educational facilities;
- compulsory examinations for admissions to aged care facilities; or
- vision screening.
By way of example, digital imaging services such as retinal photography are currently offered at many optometry practices, and because these are not rebateable under the optometry section of the MBS, optometrists may charge a private fee for providing those services.
Any consultation associated with prescribing and fitting contact lenses where the requirements of the MBS are not met may be charged at any fee negotiated between the patient and the provider. The contact lens item may not be charged unless, and until, the patient takes delivery of the contact lenses. In some cases, where the patient decides not to proceed with contact lenses, no Medicare fee is payable because the patient has not taken delivery of lenses. In such instances the patient may be charged a non-rebateable (private) fee for a ‘part’ service.
Medicare benefits are not payable in circumstances where patients want contact lenses for:
- reasons of appearance (because they do not want to wear spectacles);
- sporting purposes;
- work purposes; or
- psychological reasons (because they cannot cope with spectacles).
Private Health Insurance
Health insurers offer benefits for various goods and services under General Treatment (also known as ancillary or extras cover) policies. This can include the provision of spectacles and optometry services. Individual health insurers can determine which services they want to cover and any limits on benefits they will pay. If a General Treatment item attracts a Medicare rebate, then health insurers are not permitted to offer a rebate for that item.