Policies and strategies
We advise the Australian Government on:
- Medicare policy
- decisions about which health services to include on the Medicare Benefits Schedule (MBS), with advice from the Medical Services Advisory Committee (MSAC) and the MBS Review Advisory Committee (MRAC)
- decisions about which medicines to include on the Pharmaceutical Benefits Scheme (PBS) Schedule, with advice from the Pharmaceutical Benefits Advisory Committee (PBAC)
- the benefit amount for each service that Medicare covers
- the thresholds for the Medicare safety nets and PBS safety nets.
We jointly fund public hospitals with the state and territory governments, under the National Health Reform Agreement.
We conduct independent reviews and reforms to make sure our healthcare system stays up to date with the latest research and practices.
Legislation and regulation
Medicare is governed by laws that cover:
- what can be claimed
- who can claim
- the amount of benefits
- who manages payments and services
- who administers Medicare.
These are the:
Dental Benefits Act 2008 – governs the provision of dental services to children under the Child Dental Benefits Schedule (CDBS)
Health Insurance Act 1973 – governs the MBS and Shared Debt Recovery Scheme
Health Insurance (Medicare Compliance Shared Debt) Instrument 2019 – sets the recoverable amounts for the Shared Debt Recovery Scheme
Human Services (Medicare) Act 1973 – sets out the functions and powers for the administration of Medicare, including benefit payments, audits and fraud investigations.
National Health Act 1953 – governs the operations of the PBS
- National Health (Listing of Pharmaceutical Benefits) Instrument 2012 – governs PBS benefits, including listed medicines, who can dispense or prescribe them, and how they can be prescribed.
- National Health (Pharmaceutical Benefits) Regulations 2017 – allow the use of electronic prescriptions under the PBS
Public Governance, Performance and Accountability Act 2013 – holds us accountable for payments we make under Medicare.
Accreditation and standards
To access Medicare benefits, pathology and diagnostic imaging services listed on the MBS must be accreditated and meet standards.
We develop policy and hold regulatory responsibilities for accreditation.
The Australian Commission on Safety and Quality in Health Care develops the standards and oversees the accreditation process.
Read more about accreditation and standards for Medicare eligibility for diagnostic imaging and pathology.
All health practitioners in Australia must meet certain requirements to bill their patients under Medicare.
We have a strong program that protects Australia’s health payments system from incorrect claiming, inappropriate practice, and fraud.
Read more about what we’re doing to ensure compliance with Medicare obligations. This includes identifying and investigating potential fraud, inappropriate practice and incorrect billing under Medicare through different types of compliance activities.
Initiatives and programs
We have several initiatives and programs to support patients and healthcare providers under Medicare, including:
- Better Access Initiative – gives Medicare rebates to help people access mental health professionals and care, regardless of where they live
- Practice Incentives Program – encourages general practices to provide quality care, increase capacity, and improve access and health outcomes for patients
Quality Use of Pathology Program – provides grants for projects that improve pathology referrals, pathology practices and patient care
- Radiation Oncology Health Program Grants – helps public and private radiation oncology providers to buy eligible radiation therapy equipment.
See all our Medicare initiatives and programs.
We consult stakeholders and the public about matters related to Medicare through our Consultation Hub.
This includes when we conduct reviews and reforms of various aspects of Medicare.
Who we work with
Medical Services Advisory Committee
The MSAC assesses a range of medical services, technologies and programs and provides advice on whether they should be publicly funded, and what circumstances, if any, should apply to such funding.
Using the best available evidence, MSAC considers their:
- comparative safety
- clinical effectiveness
- cost effectiveness.
The MSAC advises on whether they should be listed on the MBS, or subsidised through other programs.
Pharmaceutical Benefits Advisory Committee
The PBAC assesses medicines and vaccines for clinical effectiveness, safety and cost effectiveness (‘value for money’) compared with other treatments. It advises on whether an item should be listed on the PBS Schedule or funded under the National Immunisation Program.
Australian Commission on Safety and Quality in Health Care
The Australian Commission on Safety and Quality in Health Care helps improve health care in Australia through:
- national safety and quality standards
- clinical care standards.
Professional Services Review
The Professional Services Review (PSR) reviews possible inappropriate practice by health practitioners when they provide MBS services or prescribe PBS medicines. This is part of our compliance program to ensure the integrity of our healthcare system.
Services Australia supports patients and health practitioners to access Medicare through:
- enrolment and cards
- claims and payments
- information about entitlements and rebates.