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Medicare is Australia’s public health system. It provides Australian citizens, permanent residents and visitors from the 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.
While Medicare covers hospital treatment as a public patient in a public hospital, private health insurance provides additional options such as:
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.
Thinking about private? Compare your options
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:
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 is what Medicare will not cover under most circumstances:
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:
Just remember that Medicare doesn't cover most dental treatments and that includes X-rays related to dental work.
The amount Medicare pays toward your treatment varies based on where you are being treated:
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 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.
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.
Yes. Medicare will pay for any anaesthesia that is part of a Medicare-covered surgery or treatment. It will pay 100% of the anesthesia 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.
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:
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:
You will need to have your Medicare card and bank account details including BSB, account number and account name with you when you register.
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:
There are other special Medicare benefits available for certain people in certain situations. These include:
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.
Picture: TK Kurikawa / Shutterstock.com
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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
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
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?
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
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?
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
Can I claim on a surgeon’s assistant’s fee?
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
Am I able to claim costs on a chest imaging at Knox Private hospital
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 a 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
CAN I CLAIM ITEM NUMBER ‘TORF’ ON MEDICARE
Hi Fran,
Thank you for leaving a question.
You may call Medicare directly to inquire about claiming the item number you mentioned. Please call 132 011. This number is open 24 hours a day, 7 days a week. Hope this helps.
Cheers,
Reggie
Can I claim for new or replacement prescription eyeglasses?
Hello Barry,
Thank you for your comment.
As per our optical health insurance page, prescription glasses and contact lenses aren’t covered by Medicare. This means that you can’t make a claim on prescription glasses.
Should you wish to have real-time answers to your questions, try our chatbox on the lower right corner of our page.
Regards,
Jhezelyn
I’m married working part time ,and I need some cosmetic dental ,can Medicare help me with charges for my procedures?
Hi Shereen,
Thank you for your question.
Generally, dental procedures for mainly cosmetic purposes are usually not covered, although those for necessary purposes that happen to have cosmetic benefits are more likely to be covered.
You will need to contact the Department of Human Services directly to see if you are eligible to claim for cosmetic dental or not.
All the best,
Zubair