Recognition as a specialist or consultant physician for Medicare 012-42020100

There are 3 sections under the Health Insurance Act 1973 to be considered for specialist recognition, these are:

• Section 3D - applies to permanent residents and Australian citizens. This applies for recognition as a specialist only and not consultant physicians. The relevant college will tell Services Australia (the agency) that the medical practitioner is now a fellow having successfully completed their course of study
• Section 3DB - applies to a permanent resident or Australian citizen who has fellowship with an Australasian college or is recognised as a specialist with the Australian Health Practitioner Regulation Agency (Ahpra). The medical practitioner may be subject to section 19AB if they are an overseas trained doctor (OTD) or foreign graduate of an accredited medical school (FGAMS). For medical practitioners who do not hold fellowship and are recognised as a specialist with Ahpra, recognition can only be granted for a period of 2 years
• Section 3E - applies to temporary residents who have fellowship with an Australasian college or are recognised as a specialist with Ahpra. For medical practitioners who do not hold fellowship with an Australasian college and are recognised as a specialist with Ahpra, recognition can only be granted for a period of 2 years. Medical practitioners previously granted specialist recognition under section 3E are required to reapply for specialist recognition every 2 years or if they become a permanent resident or Australian citizen

Consultant physician

• Has successfully completed training in their specialty and holds Fellowship of the Royal Australasian College of Physicians, Royal Australian and New Zealand College of Psychiatrists or the Australasian Faculty of Rehabilitation Medicine, or
• Registered as a specialist with the Medical Board of Australia in Psychiatry, Rehabilitation Medicine or one or more of the specialties listed against the Royal Australasian College of Physicians in Schedule 1 of the Health Insurance Regulations 2018

Medicare recognition:

• A Determination is made by the delegate of the Chief Executive Medicare and the Minister for Health recognising the medical practitioner under section 3DB or 3E of the Health Insurance Act 1973

Specialist

• Has successfully completed training in their specialty and holds Fellowship with the relevant Australasian specialist medical college in Schedule 4 of the Health Insurance Regulations, or
• Is registered as a specialist with the Medical Board of Australia in one or more of the specialties listed against an Australian specialist medical college in Schedule 1 of the Health Insurance Regulations 2018

Medicare recognition:

• A Determination is made by the delegate of the Chief Executive Medicare and the Minister for Health recognising the medical practitioner under section 3DB or 3E of the Health Insurance Act 1973, or
• Is recognised by the delegate of the Chief Executive Medicare under section 3D of the Health Insurance Act 1973 on advice from an Australasian specialist medical college that the medical practitioner satisfies the criteria for recognition

See Specialty List for Medicare purposes in Resources for a list of the relevant Australasian specialist medical colleges.

These applications are referred to as 3D applications.

Under section 3D of the Health Insurance Act 1973:

• the medical practitioner does not have to apply directly to the agency for recognition
• an Australasian specialist medical college will tell the Chief Executive Medicare that a medical practitioner has obtained fellowship for their specialty and satisfies the criteria for recognition as a specialist
• the delegate tells the medical practitioner in writing of their recognition and the date of effect

The criteria for recognition is set out in section 3D of the Act and only applies to specialists who are permanent residents or Australian citizens (excludes consultant physicians). This is not applicable to temporary residents including New Zealand residents.

3D notifications are received directly from a specialist college via email. Note: this section is reserved for specialists accessing Group A3 items.

Notifications from the following colleges cannot be recognised under 3D:

• Royal Australasian College of Physicians (RACP)
• Royal Australasian College of Physicians, Australasian Faculty of Occupational and Environmental Medicine
• Royal Australian and New Zealand College of Psychiatrists (RANZCP)

Colleges currently sending 3D notices, which can be recognised under section 3D are:

• Australasian College for Emergency Medicine (ACEM)
• Australasian College of Sport and Exercise Physicians (ACSEP)
• Australian and New Zealand College of Anaesthetists (ANZCA)
• Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine
• Australasian College of Dermatologists (ACD)
• Royal Australian and New Zealand College of Radiologists (RANZCR)
• Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)
• Royal Australian and New Zealand College of Ophthalmologists (RANZCO)
• Royal College of Pathologists of Australasia (RCPA)
• College of Intensive Care Medicine of Australia and New Zealand (CICM)

If a college not listed above provides a 3D notification, do not return it. Escalate to Local Peer Support (LPS) to review and update the above list. LPS will forward to a Programme Officer (PO) for advice, if required.

Applications for specialist recognition are considered by the delegate of the Chief Executive Medicare and the Minister for Health under section 3DB (permanent residents or Australian citizens) or 3E (temporary residents) of the Health Insurance Act 1973. The delegate makes a determination and tells the applicant in writing of the outcome.

The date of recognition may be a date in the past but cannot be earlier than the date the medical practitioner satisfied the criteria for recognition as a specialist or consultant physician.

The date Medicare billing can start may not always be the date of recognition as other factors must be taken into account. For example, if a medical practitioner is an overseas trained doctor (OTD), they must hold a valid section 19AB exemption to access Medicare benefits. Access to Medicare benefits will be determined by the dates and locations specified in the section 19AB exemption.

If a determination was made under section 3E, the medical practitioner must tell the agency when they become a permanent resident or Australian citizen. They need to re-apply for specialist recognition under section 3DB.

A specialist or consultant physician may have their recognition revoked for a variety of reasons. For example, where:

• a written request is received from the person
• the specialist or consultant physician stops to be a medical practitioner as defined in the Health Insurance Act 1973
• advice is received from the Australasian specialist medical college
• the specialist or consultant physician was incorrectly assessed as being eligible for recognition or the determination was approved with the wrong specialty

A recognised specialist or consultant physician may submit a written request to have their recognition revoked. The revocation will take effect from the date the request is received by the agency. Recognition cannot be revoked from an earlier date.

Revoking specialist recognition means the agency no longer recognises the medical practitioner as a specialist or consultant physician for Medicare purposes.

An Australasian specialist medical college may tell the Chief Executive Medicare in writing that a medical practitioner no longer satisfies the criteria for recognition or has stopped to practise medicine. Access to Medicare benefits will stop from the date the agency receives the notification.

The agency has no role in the decision making processes of the Australasian specialist medical colleges and there are no appeal rights with the agency. If a medical practitioner is not satisfied with a decision made by the college they must contact the relevant college.

The Health Insurance Act 1973 makes no provision for the Administrative Review Tribunal or any other tribunal to review determinations for specialist recognition.

A medical practitioner who is dissatisfied with the outcome of their recognition can make an application to the Federal Court under the Administrative Decisions (Judicial Review) Act 1977. However, a court can only consider alleged legal errors in the decision making process and does not have the power to change a Determination.

Medical practitioners can request to have their specialist recognition backdated. As specialist recognition is for the purpose of accessing Medicare benefits. The medical practitioner will need to provide reasons why they are seeking specialist recognition (for example, they have been unable to claim Medicare) and provide evidence to support their request (for example, evidence of Medicare claims being rejected).