What Medicare covers

What Medicare covers

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As the basis of Australia's health care system, Medicare covers many health care costs. Private health insurance provides additional cover for some services not covered by Medicare. You can choose whether to have Medicare cover only or a combination of Medicare and private health insurance.

Australia's Medicare system is available to all permanent residents. Norfolk Island does not participate in the Medicare program, however Australian citizens who have been living in Australia and move to Norfolk Island from the mainland will be eligible for Medicare on return visits for up to five years.

Overseas students and visitors on temporary visas are not eligible for Medicare benefits, unless they are from a country with which Australia has a 'Reciprocal Health Care Agreement'. See the sections on overseas students and overseas visitors for further information.

The Medicare system has three parts: hospital, medical and pharmaceutical.

Hospital

Public patient

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.

Private patient

As a private patient you have the right to 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 will be charged for the remaining 25% of the MBS fee for doctors' services, 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.

Treatment as a private patient in a private hospital can be very expensive. Private health insurance will cover some or all of these costs.

Medical

When 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. If your doctor bills Medicare directly, 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.

Pharmaceutical

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 with the medicine, up to a standard maximum. People with concession cards have a lower maximum payment.

What is not covered?

Ambulance

Medicare does not cover the cost of emergency or other ambulance services. In Queensland and Tasmania, this service is provided free by the state government. NSW and ACT provide free ambulance cover for pensioners and low income earners.

In other states, you can arrange ambulance cover yourself from the ambulance authority in your state. Alternatively, you can arrange cover with your health insurer as part of your Hospital or General Treatment cover.

Note that ambulance cover can vary - some insurers provide cover for all ambulance travel, while others only provide for ground travel or other limited arrangements, such as in your state of residence only. Check the details with your insurer to ensure which type of ambulance cover best suits your needs.

Hospital

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.

Medical

examinations for life insurance, superannuation or memberships for which someone else is responsible (for example, a compensation insurer, employer or government authority),
most dental examinations and treatment,
physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology,
acupuncture (unless part of a doctor's consultation),
glasses and contact lenses,
hearing aids and other appliances.

Other health costs

home nursing

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

More information

The Medicare website has more information on