Eyecare practitioners are being advised to prepare for potential disruption to patient billing pathways, with the federal government considering changes that would prevent most patients from claiming private health insurance (PHI) benefits for intravitreal injections delivered in private day surgeries or private eye hospitals.
Macular Disease Foundation Australia (MDFA) has been consulted by the Department of Health, Disability and Ageing regarding planned amendments to the MBS items for eye injections, currently scheduled to take effect on 1 July 2026. The original implementation date of 1 July 2025 was postponed following MDFA’s advocacy.
If enacted, the proposed change would remove PHI eligibility for the majority of patients receiving intravitreal therapy in private facilities, affecting an estimated 12,200 people.
For clinicians managing neovascular AMD and other macular diseases, MDFA warns the change risks compounding already-severe affordability barriers. More than 109,000 Australians currently receive sight-saving injections in the private system, largely due to limited availability of public outpatient services.
Unlike other chronic conditions, AMD treatment requires frequent, long-term (and often lifelong) intravitreal therapy. With many public hospital clinics at capacity, private care remains the only viable option for most patients. However, cumulative out-of-pocket costs including injections, consultations, low vision aids, support services and travel, already pose a significant burden.
Persistence data remain a concern, with approximately 50% of patients discontinuing treatment within five years, and cost frequently cited as a primary factor. Clinicians routinely see patients weigh treatment adherence against financial pressures.
MDFA is urging the government to delay any MBS amendments until broader systemic reforms improve affordability and expand public-service capacity.
MDFA’s key recommendations for reform
To mitigate patient drop-out and protect continuity of care, MDFA has submitted three recommendations alongside the call to delay the MBS change:
1. Reform the Extended Medicare Safety Net (EMSN)
MDFA proposes that for pension card holders receiving long-term treatment for neovascular AMD, the EMSN should not reset each calendar year from the second year of treatment onwards, thereby reducing cumulative out-of-pocket exposure for ongoing private injections.
2. Create a neovascular AMD treatment incentive program
Modelled on the GP Practice Incentives Program, MDFA recommends a funding mechanism that would incentivise ophthalmologists to bulk bill pension card holders for intravitreal injections, supporting those at highest risk of treatment discontinuation due to cost.
3. Integrate pharmaceutical reform agreements into the National Health Reform Agreement
This would ensure that PBS-listed anti-VEGF agents are available and adequately funded in public hospital outpatient injection clinics nationally, addressing widespread gaps in public-sector access.
Call to action for practitioners and patients
MDFA continues to advocate for a system-wide solution that ensures no patient discontinues treatment due to government policy changes. The organisation is encouraging supporters to download and submit a template letter calling for further delay of the proposed MBS changes until affordability reforms are in place.
Eyecare practitioners seeking to support the advocacy effort or help patients voice concerns can access the letter template through MDFA’s campaign materials.
