What does Medicare cover?

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:

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.

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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

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

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.

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.

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.

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.

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Frequently asked questions

• Does Medicare cover surgery?

  Yes. Medicare covers most medically necessary surgeries, and you can find a list of these 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 anaesthesia, 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, anaesthesia and diagnostic work. You and your private health insurer will be responsible for the rest including 100% of the fees.

• Can I make a specialist claim through Medicare?

  Yes. Medicare will cover your specialist visits as long as a GP refers you and as long as it's a service listed on the MBS. This includes visits to dermatologists, psychiatrists, cardiologists and many others. If the specialist bulk bills, Medicare will cover 100% of the cost. If they don't bulk bill, Medicare will cover 85% of the public rate and you will be responsible for the additional 15% plus any private premium the specialist charges.

• Does Medicare reimburse anaesthetist fees?

  Yes. Medicare will pay for any anaesthesia that is part of a Medicare-covered surgery or treatment. It will pay 100% of the anaesthesia cost if the treatment is done in a public hospital leaving you with zero out-of-pocket expenses. Medicare will split the bill with your private health insurer if the treatment is done in a private hospital - although there may also be a gap that you'll have to pay yourself.

• Does Medicare cover the cost of MRI?

  Medicare will cover the cost of an MRI scan in a public hospital, if required for treatment. If you want treatment in a private hospital, however, you'll need health insurance that covers MRI.

• Are X-rays covered by Medicare?

  Medicare covers the X-rays a doctor needs to help them diagnose or treat an illness, as long as it is considered medically necessary in a public hospital. This also includes other types of medical imaging techniques like CT Scans and MRIs. The amount Medicare will pay depends on where you are treated:

  • In a public hospital. Medicare will pay 100% of the cost of your X-ray.
  • In a private hospital. Medicare will pay 75% of the public rate and your private insurer will pay the additional 25%. If the cost is higher than the public rate, you will be responsible for the difference.
  • In an outpatient setting. Medicare will pay 85% of the public rate and you will be responsible for the rest. Private health insurance doesn't usually cover outpatient services.

  Just remember that Medicare doesn't cover most dental treatments, which includes X-rays related to dental work.