When it comes to Medicare and claiming healthcare expenses, it can get confusing. Like many Australians, you’re probably thinking, ‘What does Medicare cover and not cover?’
Let’s help you understand this topic.
Medicare is Australia’s national public healthcare system that provides many Australian residents with access to a range of healthcare services at no cost or a reduced cost. For Australians without private health insurance, Medicare eliminates or helps lessen the cost of these services. Keep in mind that Medicare doesn’t cover all medical treatment and operations.
With Medicare, you’re covered fully or partly for:
Medicare covers you to be treated as a public patient in a public hospital, at no cost, by a doctor assigned to you, if you’re admitted into hospital. As a public patient, you’ll be placed on a public hospital waiting list for the surgeries and treatments you need.
Medicare pays the costs of healthcare in line with the Medicare Benefits Schedule (MBS). The MBS is a list of services for which Medicare will pay all or some of the costs. The MBS schedule includes an indicative fee for each service with an indication of up to how much you can claim. For the full list, see the MBS.
If you want to see a certain doctor or have your own room, then you need to be admitted as a private patient. Without private health insurance, you’ll incur out-of-pocket expenses for this treatment.
If you visit the hospital for an appointment to have tests or to see a specialist and you’re not admitted, this is considered an outpatient service. In this instance, Medicare will pay 85% of the MBS fee for the treatment or service. You’ll then need to pay the remaining out-of-pocket fees, including anything extra if your doctor or specialist charges above the MBS fee.
Medicare won’t cover the following:
The Reciprocal Health Care Agreement allows people from participating countries access to Medicare. At time of writing, Australia has an agreement with 11 countries that covers the cost of medically necessary healthcare when Australians visit these countries and people from these countries visit Australia.
When you visit the GP or a specialist, Medicare covers you at the following percentages:
Medicare also covers all or part of the costs for the following services:
Medicare doesn’t subsidise all out-of-hospital services and treatment, items such as:
for the above items, you may want to consider extras health insurance if you need cover. Extras cover is designed to cover out-of-hospital medical care that Medicare doesn’t subsidise. The price of this type of policy is usually peanuts compared to the value of services you can receive, so it’s worth comparing cover options to find a great deal.
Our free comparison tool makes it easy to weigh up a range of extras policies to see which covers the services and treatment you require – at a competitive price.
In Australia, the Pharmaceutical Benefits Scheme (PBS) helps you access PBS-listed prescription medication at a reduced price. You’ll pay part of the cost of most prescription medications, and the PBS covers the rest. Concession cardholders may pay an even lower price.
It’s worth noting that not all prescription medications are on the PBS, so consult with your health professional for further clarification regarding the cost of prescribed medicines.
If you have a comprehensive extras policy, you might be able to claim some non-PBS medications.
See which medications are on the PBS.
The following people are eligible for Medicare in Australia:
If your doctor doesn’t bulk bill, you pay the difference between what they charge and what Medicare covers (the gap).
For example: Taylor is sick and decides to visit a GP; the MBS fee for that visit is $100. However, the GP charges Taylor above the recommended MBS fee, and they charge $120. The difference ($20) is called the gap payment. This gap is the amount Taylor must pay.
To find a doctor who bulk bills, use the find a health service tool on the Australian Government’s healthdirect website.
The easiest way is at the point of contact – your doctor’s office or hospital. This is done through the Medicare system electronically. All you need is to be enrolled in Medicare and show your Medicare card. It’s that simple.
However, if your provider doesn’t have this facility, you can alternatively claim through:
Medicare is funded by the Australian Federal Government via the Medicare levy, which is payable by you during tax time. At the time of writing, the Medicare levy is charged at two per cent of your taxable income on top of the tax you pay.
The government also funds Medicare through the Medicare Levy Surcharge (MLS). The MLS is charged up to 1.5% to Australian residents who do not have private health insurance and earn over $90,000 as a single or $180,000 as a couple/family annually.
The Medicare Safety Net is a government initiative designed to reduce your out-of-pocket medical costs if you require regular doctor visits and tests. The Safety Net kicks in when you spend over a certain threshold within a calendar year – this threshold then resets at the beginning of the new year.
While your doctors’ visits and tests will still cost you the same, you’ll receive a higher amount back from Medicare if you exceed the thresholds for certain Medicare services.
1 Australian Government Department of Human Services – What’s covered by Medicare. Sourced January 2020.