What is covered?

In Australia, Medicare provides universal health insurance that delivers affordable, accessible and high-quality health care for citizens and permanent residents. However you can also choose to take out private health insurance to give you more health care options and to cover items which aren't covered on Medicare.

Below is a side by side summary of what is covered by private health insurance and what Medicare covers for hospital, medical services and general treatment, pharmaceutical benefits and ambulance.

Since 2007 funds have also been able to cover a variety of alternatives to hospital treatment, known as Broader Health Cover.

Hospital

Private CoverMedicare

You can choose to be treated as a private patient in either a public OR a private hospital.

You can choose your own doctor, and decide whether you will go to a public or a private hospital that your doctor attends. You may also have more choice as to when you are admitted to hospital.

If you choose to be treated as a private patient in a hospital (public or private), Medicare will cover you for 75% of the Medicare Benefits Schedule (MBS) fee for associated medical costs.

You can be treated as a public patient in a public hospital by a doctor appointed by the hospital.

You cannot choose your own doctor and you may not have a choice about when you are admitted to hospital.

You can choose to be treated as a public patient even if you are privately insured.

The remaining hospital and medical costs will be charged to you - some or all of these costs may be covered on your private health insurance, depending on your policy.

The remaining costs include 25% of the MBS fee for doctors' services and any amount the doctors charge above the MBS fee, plus some or all the costs of:

  • hospital accommodation,
  • theatre fees,
  • intensive care,
  • drugs, dressings and other consumables,
  • prostheses (surgically implanted),
  • diagnostic tests,
  • pharmaceuticals, and
  • any additional doctor's fees.

As a public patient you will be treated at no charge.

Medicare does not cover:

  • private patient hospital costs (for example, theatre fees or accommodation),
  • medical and hospital costs incurred overseas,
  • medical services which are not clinically necessary, or surgery solely for cosmetic reasons.

For further information please see:

Medical Services and General Treatment

Private CoverMedicare
If you visit a doctor outside a hospital, Medicare will reimburse 100% of the MBS fee for a general practitioner and 85% of the MBS fee for a specialist - this applies whether or not you hold private health insurance. If your doctor bills Medicare directly (bulk billing), you will not have to pay anything.

Medicare does not provide benefits for the following:

  • 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
  • home nursing.

You can arrange private health insurance to cover many of these services.

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

For further information please see:

Pharmaceutical

Private CoverMedicare

Under the Pharmaceutical Benefits Scheme (PBS), you pay only part of the cost of most prescription medicines purchased at pharmacies - this applies whether or not you hold private health insurance. 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 with the medicine, up to a standard maximum. People with concession cards have a lower maximum payment.

You can arrange private health insurance to cover many prescription medicines which aren't listed on the PBS. Most funds will require you to make a co-payment towards the cost and will have limits on how much you can claim.Some prescription medicines are not listed on the PBS. You pay the full amount for these non-PBS items.

Ambulance

Private CoverMedicare
In Queensland and Tasmania, emergency ambulance services are provided free by the State Government. New South Wales and Australian Capital Territory provide free ambulance cover for pensioners and low income earners.
If you do not fall into any category above you can arrange ambulance cover from the ambulance authority in your state or with a health fund.Medicare does not cover the cost of emergency or other ambulance services.

For further information please see: