Medicare

Introduced in 1984, Medicare provides access to basic health services for all Australians. Medicare gives consumers access to free treatment as a public patient in a public hospital and free or subsidised treatment by some medical practitioners.

What does Medicare actually cover you for?

The Federal Government established a set of services and fees, called the Medicare Benefits Schedule (MBS), which outlines exactly what procedures Medicare covers and how much it will pay for pay for each.

However, medical practitioners may choose to charge above the scheduled fee. Medicare won't cover the extra and patients must pay this ‘gap'.

Read our article on Avoiding the Gap.

The benefits Medicare provides is split into three parts:

  1. Hospital
  2. Medical
  3. Pharmaceutical

1. Hospital

Free treatment as a public patient in a public hospital by appointed doctors and specialists. You won't be charged any fees at all.

2. Medical

In-hospital:

  • Free treatment as a public patient in a public hospital by appointed doctors and specialists. You won't be charged any fees at all for either your accommodation or medical treatment.
  • If you choose to be treated as a private patient in either a public or private hospital you choose your own doctor. Medicare will pay 75 per cent of the MBS fee for the services provided by your practitioner. You must pay the balance yourself. You will also be charged for hospital accommodation, theatre fees and medicines. These costs, as well as the balance of your doctor's costs, may be covered by private health insurance.

Out of Hospital:

If your practitioner bulk bills then you don't have to pay anything. If your practitioner does not bulk bill then Medicare pays for 85 per cent of the MBS fee and you pay the difference between the doctor's fee and the 85 per cent rebate.

Out of hospital benefits are provided for:

  • Doctors' consultation fees.
  • Tests and examinations that are required to treat illnesses, for example x-rays and pathology tests.
  • Most surgical and therapeutic procedures performed by doctors.
  • Some surgical procedures performed by approved dentists.
  • Eye examinations and essential contact lense fittings performed by participating optometrists.
  • Some cleft lip and cleft palate procedures.

3. Pharmaceutical

Medicare covers part of the cost of prescription medicines under the Pharmaceutical Benefits Scheme (PBS).

What Medicare doesn't cover

  • Private patient hospital costs, for example theatre fees and accommodation.
  • Dental examinations and treatment.
  • Glasses and contact lenses.
  • Physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry and psychology.
  • Acupuncture, unless part of a doctor's consultation.
  • Home nursing.
  • Hearing aids and other appliances.
  • Ambulance services.
  • Prosthetics.
  • Medicines.
  • Overseas medical and hospital costs.
  • Medical costs under the responsibility of a third party for example compensation insurer, employer, government.
  • Medical services that are not clinically necessary.
  • Cosmetic surgery for purely cosmetic purposes.
  • Examinations for life insurance, etc.
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