Overseas trained doctors and foreign graduates eligibility requirements

Under section 19AB of the Health Insurance Act 1973 (the Act), there’s a 10 year restriction on Medicare provider numbers for:

• overseas trained doctors (OTDs)
• foreign graduates of an accredited medical school (FGAMS).

Definitions

You’re an OTD if you got your primary medical qualification from a medical school outside Australia or New Zealand.

You’re an FGAMS if you:

• got your primary medical qualification from an accredited medical school in Australia or New Zealand
• weren’t a permanent resident or citizen of Australia or New Zealand when you enrolled in the medical school.

Section 19AB restrictions and exemptions

Under section 19AB of the Act, access to Medicare benefits is restricted for OTDs and FGAMS who either:

• got their first medical registration on or after 1 January 1997
• became a permanent Australian resident or citizen on or after 1 January 1997.

If this applies to you, there is a restriction for 10 years. You can apply for an exemption from this restriction. If you get an exemption, you can claim Medicare benefits at the location where you’ll practice.

The 10 year moratorium

To apply to access Medicare benefits while under the moratorium, you need an exemption to get Medicare benefits at your practice location.

To get the exemption you’ll also need to practice in either:

• a distribution priority area (DPA) for general practitioners
• a district of workforce shortage (DWS) for specialists.

If you’re a temporary resident, you must always meet the criteria in section 19AB.

Once you’re a permanent resident or Australian citizen there’ll be an end date on your restriction. This will be 10 years from when you registered with an Australian medical board.

It’s important to tell us if you change residency because this impacts your access to Medicare benefits.

You can find out more about DPA on the DoctorConnect website.

Applying for a section 19AB exemption

We’ll assess you for a section 19AB exemption when you apply for an initial Medicare provider number and each time you apply for a new provider number. You must tell us if you become a permanent resident or Australian citizen. Then we’ll either:

• add your name to a class exemption under section 19AB if you’re eligible
• apply to the Department of Health and Aged Care (Health and Aged Care) for an individual exemption on your behalf.

The class exemption fact sheet on the DoctorConnect website shows the type of work that class exemptions cover.

If Health and Aged Care needs to assess your application, it may take them up to 28 days.

If Health and Aged Care grants you an exemption, it’s sent back to us so we can either:

• give you a Medicare provider number
• confirm your eligibility to use your existing provider number.

You can still provide medical services but you can’t claim a Medicare benefit until you have an exemption in place. The exemption has to be for the location where you’re practicing and it can’t be backdated.

Reducing the 10 year moratorium with scaling

OTDs and FGAMS can reduce their 10 year moratorium through a non‑cash incentive called scaling.

Scaling eligibility

We work out your eligibility for scaling each month. You’re eligible if:

• your moratorium period has started
• you have a section 19AB exemption for your practice location
• your total value of your Medicare billing is or above the $5,000 monthly threshold
• you work in an eligible Australian Standard Geographical Classification - Remoteness Area (ASGC-RA) 2-5 category.

The ASGC-RA is a geographic classification system to allow measureable comparisons between city and country Australia.

You can find out more about the ASGC-RA on the DoctorConnect website.

Scaling classification

Doctors who practice in remote areas get a bigger scaling bonus.

You can check the ASGC-RA classification of your medical practice using the locator map on the DoctorConnect website.

Scaling discounts and thresholds

You don’t need to apply for scaling discounts. You’ll get them automatically if you meet monthly eligibility criteria, including:

• meeting a schedule fee threshold of $5,000 each month
• practicing in an eligible regional or remote practice.

If you practice at more than one location, we’ll base the scaling discount on the ASGC-RA with the highest claiming activity.

We base claiming activity on dates of service and total schedule fees for eligible services. The result determines if you’ve met the value of schedule fee threshold for the month.

Scaling calculations

We make scaling calculations on the last day of the month. The calculation includes the previous 4 months but doesn’t include the current month. For example, a scaling calculation made on 28 February includes October, November, December and January.

This means we can see claims even if they have been submitted to Medicare after we have finished the monthly scaling.

You can track your scaling details and look at section 19AB exemption details in Health Professionals Online Services (HPOS).

More information

Read more about Medicare benefits for health professionals.