MHCC Mental Health Rights Manual

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Chapter 3 Section E: Access to health care

This section describes the different ways that medical treatment can be accessed in Australia. It includes information on:

3E.1: Medicare

Medicare is designed to provide universal health care for Australians. Universal health care means that those people who are eligible for Medicare can always access health care that is free or provided at a low cost. This section on Medicare has information on:

3E.1.1: Who is eligible for Medicare ?

People who live in Australia (excluding Norfolk Island) are eligible for Medicare if they:

  • are Australian citizens; or
  • have a current permanent visa to be in Australia; or
  • are New Zealand citizens; or
  • have applied for a permanent visa (excluding a parent visa), (there are conditions on this entitlement to Medicare; contact Medicare for further information on 132 011).

3E.1.2: What kinds of medical treatment does Medicare pay for?

Medicare pays all or part of the costs of a range of health care services including:

  • public hospital treatment;
  • consultation with doctors, including specialists;
  • tests and examinations needed by doctors so that they can diagnose and treat illnesses, including X-rays and pathology tests;
  • eye tests performed by optometrists;
  • most surgical and other therapeutic procedures performed by doctors;
  • some surgical procedures performed by approved dentists
  • specified items under the Cleft Lip and Palate Scheme
  • specified health services as part of the Chronic Disease Management (CDM) items (721 - 732).

You can choose who provides you with health care services outside hospitals.

Medicare pays the cost of most consultations and procedures with your GP. The doctor can usually tell you whether or not the consultation or treatment you need will be paid for by Medicare. If you are in doubt, you should ask before the consultation with the doctor begins.

For more information call Medicare on 132 011*.

* Remember, mobile phone calls to freecall numbers (numbers starting with 1800) and to Local call numbers (numbers starting with 13 or 1300) are charged to the caller at the usual mobile rate.

3E.1.3: What medical or health care services does Medicare not pay for?

Medicare does not cover the costs of such things as:

  • patient care and treatment in private hospitals or as a private patient in a public hospital (for example, theatre fees or accommodation); 
  • some regular checks, such as x-rays and ultrasound for example to detect breast cancer if patient not considered at risk;
  • dental examinations and treatment (except specified items introduced for allied health services as part of the Chronic Disease Management (CDM) items ( 721 - 732);
  • ambulance services;
  • home nursing;
  • physiotherapy; occupational therapy; speech therapy; eye therapy; chiropractic services; podiatry or psychology (unless as part of the CDM) (except specified items introduced for allied health services as part of the Allied Psychological Services (ATAPS) Program. Contact Medicare for more information, phone: 132 011*.
  • acupuncture (unless it is done as part of the treatment provided by a doctor);
  • glasses and contact lenses;
  • hearing aids and other appliances; prostheses;
  • medicines (except for the subsidy on medicines covered by the Pharmaceutical Benefits Scheme);
  • medical and hospital treatment received overseas;
  • treatments that someone else is responsible for paying for (for example, a compensation insurer, an employer, a government department or authority);
  • medical services that are not clinically necessary;
  • surgery solely for cosmetic reasons;
  • examinations for life insurance, superannuation or membership of a friendly society.

For more information, call Medicare on 132 011*.

 * Remember, mobile phone calls to freecall numbers (numbers starting with 1800) and to Local call numbers (numbers starting with 13 or 1300) are charged to the caller at the usual mobile rate.

3E.1.4: How does Medicare work?

Medicare either pays the cost of a health care service up front through what is called 'bulk billing' (see below) or will pay you back for all or part of the amount you have paid for health care services.

You need to have a Medicare card to get the benefit of Medicare paying for the eligible medical treatments . If for some reason you do not have a Medicare card, contact a Medicare office (phone 132 011). Medicare will replace lost or misplaced cards. Your Medicare card number is written on the card. Dependant children are usually listed also on their parents' card.

Some health care professionals (including GPs, specialists and others) 'bulk bill' Medicare for the costs of health care. This means that you won't have to pay anything when you get the health service or treatment. If the health care provider doesn't bulk bill, then you will have to pay at the time you get the health service or treatment or pay on account, and then make a claim to Medicare for some or all of the amount you paid. Health care providers don't have to bulk bill. Some health care providers only bulk bill pensioners and other Health Care Card holders. Most medical specialists do not bulk bill.

If a health care provider bulk bills, the provider or a staff member will take an imprint or the details of your Medicare card and ask you to sign a form with these details and the details of the health care service or treatment you received.

If a health care provider does not bulk bill, after you have paid the bill, you can take or send the receipt to a Medicare office with the completed claim form and you will be paid back an amount of the bill (this is called a 'Medicare rebate' and is based on what the Government has agreed to pay for each treatment; these are called the 'scheduled fees'). The health care provider should tell you how much of the bill you should get back from Medicare. This will almost certainly be less than you pay the provider.

Medicare no longer provide rebates in cash, in order to do this you will need to advise Medicare of your bank details and account number, whatever the amount, and the rebate is usually refunded within 3 working days.

To find a Medicare office, click here.

There are other ways to get your Medicare rebate.

You can be paid electronically and several ways through the post.

Some of Medicare’s 242 branches across Australia currently offer Credit EFTPOS as a payment option, Credit EFTPOS terminals are configured by the Reserve Bank of Australia and use a dedicated wireless connection, or in some cases, a The Public Switched Telephone Network (PSTN) line.

You can also have the Medicare rebate paid directly into your bank account. The process for doing this involves your health care provider, so you should ask about this when you see the provider.

Another option is for you to pay only the difference between the health care provider's fee and the Medicare rebate amount. This is done through the health care provider asking you to sign a claims form assigning your Medicare rebate to them.

For more information on Medicare claims and rebate payment options, click here

Note: Health care providers can charge what they choose over and above the Medicare rebate amount (and the scheduled fee). Like any other service you get, you should ask how much you will be charged before you get the service.

For more information, call Medicare on 132 011*.

* Remember, mobile phone calls to freecall numbers (numbers starting with 1800) and to Local call numbers (numbers starting with 13 or 1300) are charged to the caller at the usual mobile rate.

3E.2: Access to Medicare and medical treatment by non-citizens

Access to Medicare to cover the cost of health care is granted to three groups of non-citizens in Australia:

  • permanent residents;
  • people waiting for completion of the processing of their permanent residency claims;
  • citizens of countries with mutual care agreements with Australia: Finland, Great Britain, Holland, Italy, Malta, Ireland and New Zealand (citizens of Italy and Malta have access for up to six months).

Tourists and those with student visas from countries other than those with mutual care agreements have to pay the costs of any medical treatment they get, including stays in public hospitals.

Access to an ambulance and emergency medical treatment at a hospital emergency department is not denied to anyone in NSW. However, after any stay in hospital, a person who is not eligible for Medicare will generally be given a bill for the costs of their hospitalisation, emergency transport and medical treatment. Many tourists get health insurance before they travel to Australia to cover these costs.

3E.3: Access to allied psychological services

There are two schemes that will help cover the cost of getting psychological and allied services,

Access to both of these schemes begins with a visit to a GP.

3E.3.1: The Better Access to allied psychological services through the Medical Benefits Scheme (MBS)

 The Better Access program under Medicare will cover the cost of people with most mental health conditions and be able to get up to 10 individual allied mental health services and 10 group therapy sessions each calendar year.

In order to access this benefit, you must be referred for the allied mental health treatment by a GP under a GP Mental Health Care Plan, through a psychiatric assessment and management plan, or by a psychiatrist or paediatrician.

The services that can be accessed under this scheme include psychological therapy services provided by eligible clinical psychologists and focused psychological strategy services provided by eligible psychologists, social workers and occupational therapists.

Like other Medicare-funded services, the costs may be bulk billed by the health care provider but a provider may also charge you a fee and you will only get a percentage back as a rebate from Medicare.

If you cannot afford to pay the fee for the service up-front, tell your GP or referring health care professional that you only want to be referred to someone who will bulk bill. (This may make it more difficult to access this scheme, as health care professionals who bulk bill may be limited in your area.) Your GP or referring health care professional could also refer you through the Better Outcomes – ATAPS scheme that only bulk bills for services.

The Australian Psychological Society has a fact sheet with more detail on the Medical Benefits Scheme (MBS) from the perspective of a service user. Click here to read the fact sheet.

3E.3.2: 'Better Outcomes' – access to allied psychological services (ATAPS)

GPs can refer people with diagnosed mental disorders to allied mental health care providers through the ATAPS scheme.

This scheme is targeted at low-income earners and all the available services are bulk billed through Medicare.

There are ATAPS programs run by most Primary Health Networks ( previously known as Medicare Locals. ATAPS programs usually provide up to 12 free sessions individual or groups therapy with a psychologist, a psychiatrist or a GP over a period of one year.

Allied health care professionals include psychologists, social workers, mental health nurses, occupational therapists and Aboriginal and Torres Strait Islander health workers with specific mental health qualifications.

Commonwealth funding to Medicare Locals ceased on 30 June 2015, thereafter Primary Health Networks (PHNs) became operational from 1 July 2015, with an establishment and transition-in period from early 2015.

There are now 10 Primary Health Networks instead of 17 Medicare Locals in NSW. Therefore each PHN covers a larger area than existed before. These have been designed to meet local needs and vary in their referral processes and eligibility criteria.

For further information about a program in your area, contact the Primary Health Network in your area. 

3E.4: Access to health care services by young people through headspace

headspace is the National Youth Mental Health Foundation's  one-stop-shops, that provide free access to the following services for young people (12 to 25 years old):

  • General health care services
  • Mental health and counselling services
  • Education, employment and other support services
  • Alcohol and other drug treatment services

You may not need a Medicare card to see a doctor or get other services at headspace. You are likely to be asked for a Medicare card to get psychological services.

Click here to go to the headspace website or to find the locations of headspace One-Stop-Shops

3E.5: Paying for medication (prescription drugs and pharmaceuticals)

The Pharmaceutical Benefits Scheme (PBS) provides for prescription medications at a subsidised (reduced) cost in Australia. However, not all prescription medications are on the PBS list of subsidised drugs.

The eligibility is the same as for Medicare and you may be required by a pharmacist to produce a Medicare card to get subsidised medicine under the PBS.

The most you can be charged for one prescription for any medication that is approved under the PBS. From 1 January 2015, you pay up to $37.70 for most PBS medicines or $6.10 if you have a concession card.

Some people are eligible for a concessional benefit that means they pay $6.10 for most prescription medications. To be eligible for a concessional benefit, you must have one of the following concession cards:

  • Pensioner Concession Card;
  • Commonwealth Seniors Health Card;
  • Health Care Card; or
  • Department of Veterans Affairs (DVA) White, Gold, or Orange Card.

Some medicines are sold under more than one name, although they are the same medication for the same conditions. Some of these are called 'generic medicines' and often are less expensive than the other medication with a more familiar brand name, even on the PBS. You may want to ask either your doctor or the pharmacist when you are prescribed medication whether there is a cheaper generic equivalent.

For more information on the PBS, click here to go to its website or call the Department of Health and Ageing PBS Information Line on 1800 020 613*. The PBS Information Line is open Monday to Friday from 8.30 am to 5.00 pm.

 *Remember, mobile phone calls to freecall numbers (numbers starting with 1800) are charged to the caller at the usual mobile rate.

3E.6: Access to dental care

One of the exceptions to universal access to health care in Australia is dental care.

Private dentists and dental technicians provide most dental care in Australia on a fee-for-service basis. There are limited circumstances in which a person can get free or subsidised dental treatment. These are described below.

3E.6.1: Paying for dental care

As with other private health services, there is no regulation of what a dentist may charge you for their services.

Always make sure when you see a private dentist that you know what they are going to charge you. If you are seeing a dentist for complex work with a large fee, it is strongly recommended that you ask for a written quote before the treatment is started. Some private dentists offer the first consultation (not treatment) for free.

3E.6.2: Free and public dental care

Under the Child Dental Benefits Scheme, children and young people between the ages of 2 and 17 are entitled to free public dental care. You can also obtain free public dental care if you have a Pensioner Concession or Health Care Card. No one else can access free public dental care, even if you are working but have little spare money and no assets. Free public dental care is only provided for essential dental care, and not usually for cosmetic dentistry.

Click here to read about the Child Dental Benefits Scheme

Public dental clinics are usually located in or near large public hospitals.

There are long waiting lists, even for some urgent dental procedures, at the public clinics. If your situation becomes more urgent, and you are on a waiting list, you should tell the dental clinic of the change in your condition. Public dental clinics only do some dental treatments. If you need other treatments, your only option may be private treatment.

3E.7: Access to Schedule 8 drugs

Schedule 8 drugs are addictive drugs. The 'schedule' is in the NSW Poisons List and it refers to the Commonwealth Standard for the Uniform Scheduling of Drugs and Poisons (the Poisons Standard). Click here to find out more about the Poisons Standard.

Examples of Schedule 8 drugs are oxycodone, morphine, pethidine, amphetamine, methadone, and ketamine. They are usually prescribed for the relief of severe pain. These drugs can be prescribed by medical practitioners (and, in restricted circumstances, by dentists).

Drugs in other schedules of the Poisons Standard can also have special conditions on their dispensing and prescribing. This information can be obtained from doctors and pharmacists.

There are restrictions on the prescription of Schedule 8 drugs that people with mental illness should be aware of.

If you are a person known to be a 'drug-dependent person', then the doctor must have an authority from the Pharmaceutical Services Branch (PSB) of NSW Health to prescribe a Schedule 8 drug to you. These authorities are reviewed and renewed regularly.

If you are not a drug-dependent person, your doctor does not need to get an authority to prescribe you a Schedule 8 drug unless the drug is packaged for the purpose of injection or is:

  • buprenorphine (except transdermal patches); or
  • flunitrazepam; or
  • hydromorphone; or
  • methadone.

A doctor cannot prescribe any of these four drugs for more than two months without getting an authority from the Pharmaceutical Services Branch.

It is important to remember that there is no legal obligation on any doctor to treat you (except when they are confronted with extreme life-threatening emergencies), and a doctor does not have to prescribe you any medication, despite the fact that another doctor or doctors may have said it is necessary for your medical condition or pain relief.

 DISCLAIMER

  • The legal and other information contained in this Section is up to date to 30 January 2015
  • This Manual only refers to the law and practices applying to the Australian state of New South Wales (NSW) - unless it states otherwise.
  • MHCC does not guarantee the accuracy nor is responsible for the content or the currency of the content of external documents and websites linked to this Manual.