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Eyes on Diabetes - Discussing Diabetic Retinopathy

Info for Health Professionals

Medicare and Optometry

Q. Does Medicare pay for examinations from optometrists?

A. Yes, Medicare pays benefits for most consultations by optometrists. There are some consultations relating to contact lenses which are not covered, depending on whether the patient meets certain conditions.

Q Who is eligible for Medicare benefits?

A. All permanent residents of Australia are eligible for Medicare benefits. Some people who are not permanent residents may also be eligible for some benefits.

Q. Do I need a referral?

A No, you do not need a referral from a doctor to see an optometrist. You simply contact your local optometrist and arrange an appointment.

Q Are all consultations covered by Medicare?

A. All consultations related to regular eye care are covered. However, some consultations relating to contact lenses are not covered. To be eligible for benefits for contact lens consultations, you must meet one of a list of conditions. These are intended to ensure that Medicare pays benefits only for people who have a clear clinical need for contact lenses.

Q. How much will it cost me to have my eyes examined?

A. The fees charged by optometrists for an eye examination may vary, but if the patient is eligible for Medicare benefits the optometrist may not charge more than the maximum fees negotiated between the Optometrists Association of Australia and the Commonwealth Government.

If your optometrist directly bills Medicare for your eye examination (bulk-bills), you will pay nothing for the examination. Medicare will pay your optometrist 85 per cent of the negotiated schedule fee for that examination, which is accepted as full payment.

If you are billed for the examination you can claim a proportion of the fee back from Medicare. The amount you can claim depends on the fee charged and whether you have had a comprehensive eye examination from another optometrist in the past two years.

Q. What happens if I have seen another optometrist in the past two years?

A. From November 1 1997, Medicare will pay a reduced benefit for a comprehensive optometric consultation if the patient has had a comprehensive consultation from another optometrist within the past two years. This change is intended to reduce Medicare costs and makes the benefit the same as that which would be payable if the patient saw the same optometrist twice within that two-year period. The best approach is to find an optometrist you trust and to return to him or her when you need an eye examination.

Q. I'm a pensioner. Will I be bulk-billed?

A. There is no requirement for optometrists to bulk-bill any person or group but it is the policy of Optometrists Association Australia that members bulk-bill Medicare on behalf of pensioners and the disadvantaged.

Q. Does Medicare cover spectacles or other optical appliances?

A. No, Medicare covers only eye examinations. It does not cover the cost of any optical appliances, such as spectacles or contact lenses, which may be prescribed. Private health funds do provide cover for optical appliances.

In most States, pensioners and others on low incomes can obtain optical appliances either free of charge or at low cost under State government schemes. Ask your optometrist about these schemes.

Useful Links

Important information can be found on the websites of associated organsiations.

Useful Links for Health Professionals

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