MEDICARE & CONNECTIVITY TO AUSTRALIA Medicare is the publicly funded Australian health system and is subsidised by a 1.5% Medicare levy, payable by all taxpayers, integrated in the pay-as-you-go payroll system and covers all Australian citizens and permanent residents regardless of their level of income. Medicare is the sole provider of all medical benefits in Australia and provides access to GP s, specialists etc. and public hospital treatment as legislated in the Health Insurance Act 1973 under; S126 S10 Prohibition of insurance for medical expenses in respect of the rendering in Australia of a professional service for which a Medicare benefit is payable. Medicare benefit is payable in respect of a professional service rendered in Australia to an eligible person ELIGIBLE PERSON S3 Australian Residents (definition attached very broad) S6(1) Individuals or classes of persons can be declared by order of the Minister to be eligible persons S6(2) Individuals or classes of persons who would otherwise be an eligible person, can be declared, by order of the Minister, NOT to be an eligible person S7 Visitors from countries which have Reciprocal Health Care Agreements with Australia are, subject to the agreement, eligible persons*. Check list 1) Whether you can write either Medicare benefits or private top up insurance, depends on whether a person is an eligible person 2) A person can be eligible under one of three categories Australian Resident Ministerial order Reciprocal Health Care Agreement* So you need to check that none of the above applies. If one does, you cannot insure either Medicare benefits or private top up insurance.if none does, precede to 3 and 4 3) You then need to check whether a person who is otherwise eligible, has that eligibility removed by ministerial order under section 6(2) of the Health Insurance Act. If so you may insure Medicare benefits 4) For private top up insurance, you then need to make sure that the element of expecting to temporarily present in Australia applies. If it does, you may write private top up insurance. *One of the categories for eligibility is the existence of a reciprocal health care agreement with another country. Eligibility by that route is subject to the reciprocal health care agreement itself. The precise wording of the agreements may give you some flexibility or other options
How Australian Expatriates are affected by National Health Act legislation and Medicare Eligibility The Statutory Position A Ministerial Order was issued under subsection 6(1) of the National Health Act, effective 31 December 1993. This order has been renewed, unaltered, on 31 December 1998, 31 December 2003, and 31 December 2008 to now expire 31 December 2014. The order in part states: Declare that every person included in the following class of persons, namely Australian citizens who have been absent from Australia for a period of no longer than five (5) years from the date of last departure, at which time such person was an Australian resident as defined in the Act still retain their entitlement to Medicare and as such, must be a member of a RHBO to receive any form of private health cover when re-entering Australia (Please note date of last departure,)this means after a permanent return, not a temporary return. PRIVATE TOP UP- INSURANCE National Health Act 1953 + National Health regulations S67 (1) Health insurance business to be carried on only by registered organizations S67 (4) Health insurance business = fees for Australian hospital treatment or an ancillary health benefit * * Ancillary health benefit (a) (f) (Definition attached) Ancillary health benefit is not (g) A professional service for which Medicare benefit is payable (h) Hospital treatment (i) Any other prescribed benefit *does not apply to (c) accident and sickness insurance business (d) liability insurance business (workers comp- motor vehicle) or (e) prescribed business
Why can t insurance companies, or any other entity, top up Medicare benefits in Australia? HEALTH INSURANCE ACT 1973 - SECT 126 Prohibition of certain medical insurance (1) A person shall not make a contract of insurance with another person that contains a provision purporting to make the first-mentioned person liable to make a payment in the event of the incurring by the other person of a liability to pay medical expenses in respect of the rendering in Australia of a professional service for which a Medicare benefit is, or but for subsection 18(4)* would be, payable. Penalty $1,000 per event. *18(4) Medicare benefit not payable where compensation payable (e.g. Workers comp) Why insurance companies do not pay Medicare related benefits? Section 67 (1) of the National Health Act 1973 states; Subsection (1) A person (other than a registered health benefits organisation) (RHBO) shall not carry on health insurance business. Subsection (2) A person who contravenes subsection (1) is, in respect of each day on which the person contravenes that subsection guilty of an offence punishable on conviction by a fine not exceeding: a) If the person is a body corporate, $20,000; or b) If the person is a natural person, $2,000 Why can insurers pay Non-Medicare benefits in Australia? Regulation 48 The relevant regulation under the National Health Act of 1973 is Regulation 48 which provides for types of businesses which may be carried on by an organisation which is not an RHBO- i.e. a general insurer such as Chubb, Ace, AIG etc. and relates to liability undertaken in respect of:- a person (and dependants), who is a resident of Australia and engaged in temporary employment outside Australia in respect of whom a contract of insurance provides that liability for hospital treatment may arise:- (i) in Australia ; or (ii) outside Australia, if the absence of the person from Australia is due to temporary employment. NOTE This does not include Medicare related medical expenses
Medicare Services Services covered by Medicare include the following: Consultation fees from doctors and specialists Eye tests performed by an optometrists Blood tests and x-rays Most surgical and therapeutic procedures performed by doctors Some surgical procedures performed by an approved dentist What is not covered by Medicare Medicare provides comprehensive medical and public hospital benefits however many services are not covered by Medicare and these can be covered by private health insurance. Some examples of what Medicare does not cover: Private hospital accommodation Most dental services Ambulance services Home nursing Physiotherapy Occupational therapy Speech therapy Podiatry Hearing aids and other appliances Chiropractic services Acupuncture Cosmetic surgery due to injury or illness Glasses and contact lenses Prostheses Medication not covered by PBS ( see below for details on PBS) Cosmetic surgery Workers Compensation claims Medical services which are not necessary Pharmaceutical Benefit Scheme (PBS) Physician-Prescribed Drugs and Medicines Australian citizens and Permanent Residents have access to a subsidised Pharmaceutical Benefits Scheme (PBS). They must show their Medicare Card when purchasing Physician-prescribed drugs and medicines to obtain the PBS rate. If a prescription is subsidised there is no refund available from health funds as they are only able to refund non- PBS items. Section 3 Health insurance Act 1973 Definition of Australian resident "Australian resident" means a person who resides in Australia and who is: (a) an Australian citizen; or (b) a person who is, within the meaning of the Migration Act 1958, the holder of a permanent visa; or (ba) a person who has been granted, or who is included in, a return endorsement or a resident return visa in force under the Migration Act 1958 ; or (c) a New Zealand citizen who is lawfully present in Australia; or
(d) a person (not being a person referred to in paragraph (a), (b), (ba) or (c)) who is lawfully present in Australia and whose continued presence in Australia is not subject to any limitation as to time imposed by law; or (f) a person who: (i) is, within the meaning of the Migration Act 1958, the holder of a temporary visa; and (ia) is not covered by regulations made under subsection 6A(1); and (ii) has applied for a permanent visa under that Act and the application has not been withdrawn or otherwise finally determined; and (iii) has not, both: (A) on or after the commencement of this paragraph, made an application for a protection visa under that Act (whether or not the person has applied for any other visa), other than an application that has been withdrawn or otherwise finally determined; and (B) whether before or after the commencement of this paragraph, made an application for a parent visa under that Act (whether or not the person has applied for any other visa and whether or not the application for the parent visa has been withdrawn or otherwise finally determined); and (iv) has not, whether before or after the commencement of this paragraph, made an application for a parent visa under that Act (whether or not the person has applied for any other visa), other than an application that has been withdrawn or otherwise finally determined; and (v) In respect of whom either: (A) another person, being the person's spouse, parent or child (each having the same meaning as in the Migration Act 1958 ), is an Australian citizen or the holder of a permanent visa under that Act; or (B) an authority to work in Australia is in force. Definition of ancillary health benefit Ancillary health benefit means; a) relevant health services b) services involving the supply, alteration, maintenance or repair of hearing aids, spectacles, contact lenses, artificial teeth,eyes or limbs(including part of the teeth or limbos)or other medical,surgical, prosthetic or dental aids, equipment or appliances. c) Drugs or medicinal preparations d) Ambulance services e) Services by an attendant of a person who is sick or disabled or f) Any other benefit, or benefit included in a class of benefits, prescribed for the purposes of this paragraph ; but does not include: g) The rendering of a professional service for which a Medicare benefit is, or for subsection 18(4) of the Health Insurance Act 1973 would be, payable: (4) Subject to subsection (4A), where, at the time at which a claim for Medicare benefit is made, it appears to the Minister that the claim may become a claim that will give rise to a determination under subsection (1), the Minister may direct that no Medicare benefit be paid at that time in respect of the claim but that there be made to the claimant a provisional payment of such amount of Medicare benefit as the Minister thinks fit. (4A) A direction under subsection (4) cannot be made on or after the day on which the Health and Other Services (Compensation) Act 1995 commences.
Suspension of Private Health Insurance The following conditions apply. A membership may be suspended when travelling overseas for work or leisure. If you are travelling overseas, you can suspend your cover for the following period of time: a minimum period of two months travel; and a maximum period of two years per suspension you can only suspend your policy twice per calendar year you must recommence paying your premiums upon resumption of your policy.one monthly contribution is required between each suspension period there is a lifetime suspension limit of 6 years Note Suspension does not guarantee automatic continuity of cover upon resumption, and Suspension of a health fund whilst on an overseas assignment does not qualify as being a financial member of a health fund with appropriate insurance For further information, please contact Berry at Willis Expatriate Risks. Contact: Berry Treffers Tel: +61 8 8224 4717 Fax: + 61 8 8223 7223 Email: treffersr@willis.com