What is covered by Medicare?
Medicare is the basis of Australia's health care system and covers many health care costs. Most Australian residents are eligible for Medicare.
You can choose whether to have Medicare cover only, or a combination of Medicare and private health insurance.
The Medicare system has three parts: hospital, medical and pharmaceutical.
Under Medicare you can be treated as a public patient in a public hospital, at no charge, by a doctor appointed by the hospital. You can choose to be treated as a public patient, even if you are privately insured.
As a public patient, you cannot choose your own doctor and you may not have a choice about when you are admitted to hospital because you may be placed on a public hospital waiting list.
Medicare does not cover:
- private patient hospital costs (for example, theatre fees or accommodation) - you can purchase private hospital insurance to cover this item;
- medical and hospital costs incurred overseas;
- medical and hospital services which are not clinically necessary, or surgery solely for cosmetic reasons;
- ambulance services; and
- emergency department administration or facility fees.
When you visit a doctor outside a hospital, Medicare will reimburse 100% of the Medicare Benefits Schedule (MBS) fee for a general practitioner and 85% of the MBS fee for service provided by a specialist. If your doctor bills Medicare directly (bulk billing), you will not have to pay anything.
Medicare provides benefits for:
- consultation fees for doctors, including specialists;
- tests and examinations by doctors needed to treat illnesses, such as x-rays and pathology tests;
- eye tests performed by optometrists;
- most surgical and other therapeutic procedures performed by doctors;
- some surgical procedures performed by approved dentists;
- specific items under the Cleft Lip and Palate Scheme;
- specific items under the Enhanced Primary Care (EPC) program; and
- specific items for allied health services as part of the Chronic Disease Management Plan.
Medicare does not cover:
- examinations for life insurance, superannuation or memberships for which someone else is responsible (for example, a compensation insurer, employer or government authority);
- ambulance services;
- most dental examinations and treatment;
- most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services;
- acupuncture (unless part of a doctor's consultation);
- glasses and contact lenses;
- hearing aids and other appliances; and
- home nursing.
Many of these items can be covered on private health insurance general treatment (extras) policies. Most insurers will have limits on how much you can claim per service and per year.
Under the Pharmaceutical Benefits Scheme (PBS) you pay only part of the cost of most prescription medicines purchased at pharmacies. The rest of the cost is covered by the PBS. You must present your Medicare card to obtain this benefit.
The amount you pay varies, and is dependent on the type of medicine, up to a standard maximum. People with Government-issued concession cards have a lower maximum payment.