What does Medicare cover?

Confused about what services you can claim for with Medicare in Australia?

Medicare is Australia’s public health system. It provides Australian citizens, permanent residents and visitors from Reciprocal Health Care Agreement (RHCA) countries with free essential health care in public hospitals. It also subsidises GP visits and essential medications through the Pharmaceutical Benefits Scheme (PBS).

This guide looks at what is covered by Medicare, what isn’t covered and how the private health system plays a necessary role by filling in the gaps to provide Australians with comprehensive medical cover.

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What’s the difference between Medicare and private health insurance?

While Medicare covers 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.

Advantages of private health cover over the public health system 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 main 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 public and private health cover.

Still not sure if Medicare is enough for you? You can check out this roundup of some key Medicare facts every Aussie needs to know.

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What can you claim on Medicare?

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. Local and general anaesthetics and anaesthetist consultations if required, along with more complex anaesthesia needs, such as for more 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).
• Dental. Strictly essential medical procedures and required orthodontics and major dental work providing it meets certain criteria (eg, treatment for a cleft palate is considered essential treatment).
• 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)

How to register for Medicare

If a treatment or service is covered by Medicare and your service provider doesn’t bulk bill, you will need to pay upfront for your treatment and claim some or all of the cost back later (100% for GP visits and 85% for specialist visits).

By registering your bank account details with Medicare, you can streamline the process, as your benefits will be paid directly into your nominated bank account. You can register in several different ways:

• Through your Medicare online account at myGov
• With the Express Plus Medicare app
• By completing a bank account details collection form
• By calling the Medicare general inquiries line
• By registering in person at your local Medicare service centre

You will need to have your Medicare card and bank account details including BSB, account number and account name with you when you register.

How to claim Medicare benefits

The fastest and easiest way to claim your Medicare benefits is at the point of service (eg, your doctor or service provider). Many are now equipped with electronic Medicare claiming facilities, which allow them to lodge your claim and have your benefits paid directly into your bank account. If your GP does not offer electronic claiming, you will need to claim your benefits in one of the following ways:

• Using your Medicare online account through myGov (note that some types of consultations cannot be claimed online)
• 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 (be sure to have your details handy including your Medicare number, your bank account details and the service provider’s receipt)

Can I get any special Medicare benefits?

There are other special Medicare benefits available for certain people in certain situations. 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 for children. Benefits for basic dental services for eligible children, which are capped at $1,000 per child over two consecutive 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 or any services provided in a hospital.
• 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.

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Where Medicare can’t help you, health insurance could pick up the slack. Less waiting time, choice of doctor and help with dental. Use this free tool to see health insurance options across Australia.

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