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What does Medicare cover?

Medicare covers treatment in public hospitals and some medications, but it doesn't cover every medical cost

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What you need to know

  • Medicare covers most essential treatments at public hospitals.
  • Medicare does not generally cover most dental, optical or ambulance costs.
  • Private health insurance can cover additional expenses as well as treatment in a private hospital.

What does Medicare cover?

Here's a more in-depth look at some of the treatments covered by Medicare. It should be noted that all treatments must be professionally prescribed by eligible, licensed practitioners and medically recognised as the correct option for that particular situation:

Testing and diagnosis

This includes X-rays, MRIs and other diagnostic techniques where they are considered necessary (eg, an eye test to diagnose cataracts is considered necessary, while an eye test for a pilot's licence is not).

Anaesthesia

This includes local and general anaesthetics - and anaesthetist consultations if required. Medicare also covers more complex anaesthesia needs, such as for complicated surgeries or health issues like drug allergies and heart disease.

Surgery

Operating theatre fees in public hospitals, required surgical consultations and surgery as a treatment if required (eg, surgery to remove a tumour is required, whereas elective cosmetic surgery is not). Some dental surgery can be included in this, but not work done by a dentist.

Medication

Approved pharmaceuticals that have been prescribed by a licensed and approved practitioner and are covered by the PBS (a government scheme that subsidises the cost of many medicines dispensed by pharmacists)

What does Medicare not cover?

While Medicare covers a lot, there are a few things it won't cover and it's good to know what these are before going into treatment. Here's what Medicare will not cover under most circumstances:

  • Ambulance rides
  • Overseas medical and hospital costs
  • Medical treatments that aren't medically necessary, like facelifts
  • Most dental treatments
  • Most physio, acupuncture, and other natural therapy treatments
  • Podiatry
  • Glasses and contacts
  • Most hearing aids and other appliances
  • Home nursing

If you want to be covered for these, you'll need to take out a private health insurance policy. You can do this for free using the table below.

Medicare vs private health insurance

While Medicare coverage includes hospital treatment as a public patient in a public hospital, private health insurance provides additional options such as:

  • Treatment as a private patient in a public hospital. Medicare pays 75% of the Medical Benefits Scheme (MBS) costs and private health insurance pays the remaining 25%.
  • Treatment as a private patient in a private hospital. Private health insurance covers some or all of the costs for accommodation, theatre fees and specialist fees.

The advantages of private health cover

Advantages of private health cover over Medicare include the choice of your own treating doctor and eligibility for a shared or private room. Another advantage is shorter waiting times for elective (non-essential) surgery. While you can wait many months (sometimes years) in the public system for a procedure such as hip surgery, wait times are usually much shorter for private health fund members.

The other big advantage of private health insurance is extras cover for ancillary services such as optical, dental and physiotherapy, none of which are covered by Medicare. Because Medicare covers some out-of-hospital services not covered by private health insurance, such as GP visits and PBS pharmaceuticals, it can be a real advantage to have a combination of both private health insurance and Medicare coverage.

Compare private health insurance

How much do I get back from Medicare?

The amount Medicare pays toward your treatment varies based on where you are being treated:

Public hospital

Public Hospital

If you are treated in a public hospital, Medicare will pay 100% of the cost for the treatment itself, the anaesthesia, all diagnostic work like blood work and x-rays and all fees like theatre fees, accommodation fees and doctor's fees.

Private hospital

Private Hospital

If you are treated in a private hospital, Medicare will pay 75% of the public rate for the treatment, the anaesthesia and all diagnostic work. You and your health insurer are responsible for the rest, including 100% of the cost of all fees like accommodation fees, doctor's fees and theatre fees.

x-ray

Outpatient Clinics

You might be treated in an outpatient for diagnostic work like X-rays, ultrasounds and blood work. Medicare will pay 85% of the public rate and you will be responsible for the rest. Private hospital insurance usually doesn't cover outpatient services.

GP Doctor

General Practitioner

If you see a GP Medicare will pay 100% of the cost if the GP bulk bills. If they don't bulk bill, Medicare will pay 100% of the public rate and you will have to pay any extra if the doctor charges more.

Specialist

Other Specialists

If you see a non-GP specialist, Medicare will pay 100% of the cost if the provider bulk bills. If they don't bulk bill, Medicare will pay 85% of the public rate and you will have to pay the additional 15% plus any extra if the doctor charges more.

Who is eligible for Medicare?

You are eligible for Medicare if you live in Australia or on an Australian dependency island such as Norfolk, Christmas and Lord Howe Island, though specific requirements and criteria apply. You must also be:

  • An Australian citizen. If you were born in Australia.
  • New Zealand citizen. You must have lived or intend to live in Australia for more than 6 months to be eligible.
  • An Australian permanent resident. If you have applied for your PR, or are disputing your PR, you are eligible for Medicare.
  • Reciprocal Health Care Agreement. You may also be entitled to a Medicare card if you're visiting from one of the 11 Reciprocal Health Care Agreement countries.
  • Living Overseas. You can also get access to Medicare if you're an Australian citizen and you live overseas. However, if you've been living overseas for more than 5 years you will no longer have access to Medicare.

How to claim Medicare benefits

You can generally claim Medicare benefits at the point of service. Most service providers have electronic claiming facilities, so they can lodge your claim on your behalf. If your GP or provider doesn't offer this,you'll need to claim your benefits in one of the following ways:

  • Using your Medicare online account through myGov
  • Using your Express Plus Medicare mobile app
  • Submitting a Medicare claim form by post, at your local service centre or at a participating private health insurer
  • Submitting a claim over the phone by calling Medicare

Other Medicare benefits

There are a few special Medicare benefits available for certain people. These include:

  • The Medicare Safety Net. This is available to all Australians with a Medicare card who exceed an annual threshold on the cost of their PBS pharmaceuticals. After the threshold is reached, you receive cheaper medicines for the remainder of the year. The threshold is considerably less for concession card holders.
  • Dental benefits under Medicare. There are benefits for basic dental services available for some children and concession card holders. Benfits for kids are capped at a little over $1,000 per child every two years. Services covered include examinations, x-rays, cleaning, fissure sealing, fillings, root canals and extractions. No benefit is payable for orthodontic or cosmetic dental work. Some state also have additional benefits on offer.
  • Pensioner medical equipment. Eligible pensioners can claim a payment towards the cost of eligible equipment such as home dialysis machines, home ventilators and respirators, oxygen concentrators, heart pumps, nebulisers, electric wheelchairs and insulin pumps.

Frequently asked questions

More guides on Finder

  • Health care and concession cards

    There are a range of concessions cards available in Australia. See your options for health care support.

  • Full medical checkups

    Learn about 10 free health checks you should get as an adult; some may even save your life.

  • Medicare Safety Net

    What is the Medicare Safety Net, how does it work and what does it mean for your out-of-pocket medical costs? Find out here.

  • What is the MBS? (Medicare Benefits Schedule)

    What is the Medicare Benefits Schedule (MBS) and what medical services does it cover? Find out in this comprehensive guide.

  • What is bulk-billing?

    What is bulk-billing and what medical services can you bulk-bill in Australia? Find out here.

  • What is the PBS?

    This guide looks at how the PBS works, who is eligible and what you’re likely to pay at the prescription counter.

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16 Responses

  1. Default Gravatar
    BrokenAnkleSeptember 5, 2019

    Hi there,
    I needed ankle surgery, after having x2 surgeries on my foot, and instead of waiting 1-2 years in the public system – I elected to go private and pay myself.
    What of the private costs could i claim on Medicare- if any?

    This was roughly 12 months ago- is there a timeframe on when i need to claim wihtin?

    Thanks

    • Default Gravatar
      NikkiSeptember 6, 2019

      Hi BrokenAnkle,

      Thanks for your message. Sorry to hear about your current situation.

      According to our review, Medicare covers most medically necessary surgeries which are found on the Medicare Benefits Schedule (MBS). Since surgeries happen mainly in hospitals, Medicare will cover 100% of all costs related to the surgery if you have it done in a public hospital. This includes anesthesia, diagnostic work, and all fees. If you have it done in a private hospital, Medicare will chip in 75% of the public rate for the surgery, anesthesia, and diagnostic work. You and your private health insurer will be responsible for the rest including 100% of the fees.

      You can also find more information on what you can claim on Medicare.

      Waiting periods vary and are different for hospital cover and general treatment (extras) cover. You can read about waiting periods for hospital insurance or contact Medicare directly to obtain this information.

      Hope this helps and feel free to reach out to us again for further assistance.

      Best,
      Nikki

  2. Default Gravatar
    ALEXApril 4, 2019

    I had a Colonoscopy procedure last week. My Health insurance (OVERSEAS STUDENT) covered 100% of the private hospital fees.

    I had to pay for the out of pocket expenses – specialist and anaesthetic. Currently, I also have Medicare. Where – private insurance or Medicare – Do I have to claim for those services refund?

    • Avatarfinder Customer Care
      JeniApril 5, 2019Staff

      Hi Alex,

      Thank you for getting in touch with Finder.

      If services are covered by Medicare, yes, that would be done in the Medicare office by submitting a claim. Not all out of pocket costs will be covered by Medicare. Please visit the nearest Medicare office on this matter to be guided on the specifics.

      I hope this helps.

      Thank you and have a wonderful day!

      Cheers,
      Jeni

  3. Default Gravatar
    MelFebruary 21, 2019

    I injured my shoulder 3 weeks ago. I have a Medicare card and pay the levy every year. Where can I find a doctor who could help me deal with my injury and let Medicare pay for it?

    • Avatarfinder Customer Care
      JoshuaFebruary 24, 2019Staff

      Hi Mel,

      Thanks for getting in touch with Finder. I’m sorry to hear about your injury.

      Regarding your question, you can find doctors in both private and public hospitals who specialize in handling your shoulder injury. Meet a doctor in those hospitals and depending on your diagnosis, you would know more whether you will be covered by Medicare or not or how much you will get covered for.

      I hope this helps. Should you have further questions, please don’t hesitate to reach us out again.

      Have a wonderful day!

      Cheers,
      Joshua

  4. Default Gravatar
    MarilynJanuary 25, 2019

    Can I claim on a surgeon’s assistant’s fee?

    • Avatarfinder Customer Care
      JeniJanuary 27, 2019Staff

      Hi Marilyn,

      Thank you for getting in touch with finder.

      If the surgery was done in a private hospital, Medicare will chip in 75% of the public rate for the surgery, anesthesia and diagnostic work only while the rest of the cost including various fees will be shouldered by you and your private health insurance.

      I’m afraid that you may not claim on surgeon’s assistant’s fee. I still suggest that you contact Medicare directly on this matter via phone or in-person at the nearest Medicare office.

      I hope this helps.

      Thank you and have a wonderful day!

      Cheers,
      Jeni

  5. Default Gravatar
    JenniferNovember 12, 2018

    Am I able to claim costs on a chest imaging at Knox Private hospital

    • Avatarfinder Customer Care
      JoshuaNovember 25, 2018Staff

      Hi Jenni,

      Thanks for getting in touch with Finder. I hope all is well with you. :)

      Yes, you may be able to claim costs on chest imaging. Medicare covers diagnostic techniques where they are considered necessary. You may check with your local Medicare office as well to confirm.

      I hope this helps. Should you have further questions, please don’t hesitate to reach out again.

      Have a wonderful day!

      Cheers,
      Joshua

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