Medicare covers most essential treatments at public hospitals.
Medicare does not generally cover most dental, optical or ambulance costs.
Private health insurance can cover additional expenses as well as treatment in a private hospital.
What does Medicare cover?
Here's a more in-depth look at some of the treatments covered by Medicare. It should be noted that all treatments must be professionally prescribed by eligible, licensed practitioners and medically recognised as the correct option for that particular situation:
Testing and diagnosis
This includes X-rays, MRIs and other diagnostic techniques where they are considered necessary (eg, an eye test to diagnose cataracts is considered necessary, while an eye test for a pilot's licence is not).
Anaesthesia
This includes local and general anaesthetics - and anaesthetist consultations if required. Medicare also covers more complex anaesthesia needs, such as for complicated surgeries or health issues like drug allergies and heart disease.
Surgery
Operating theatre fees in public hospitals, required surgical consultations and surgery as a treatment if required (eg, surgery to remove a tumour is required, whereas elective cosmetic surgery is not). Some dental surgery can be included in this, but not work done by a dentist.
Medication
Approved pharmaceuticals that have been prescribed by a licensed and approved practitioner and are covered by the PBS (a government scheme that subsidises the cost of many medicines dispensed by pharmacists)
What does Medicare not cover?
While Medicare covers a lot, there are a few things it won't cover and it's good to know what these are before going into treatment. Here's what Medicare will not cover under most circumstances:
Ambulance rides
Overseas medical and hospital costs
Medical treatments that aren't medically necessary, like facelifts
Most dental treatments
Most physio, acupuncture, and other natural therapy treatments
Podiatry
Glasses and contacts
Most hearing aids and other appliances
Home nursing
If you want to be covered for these, you'll need to take out a private health insurance policy. You can do this for free using the table below.
Medicare vs private health insurance
While Medicare coverage includes hospital treatment as a public patient in a public hospital, private health insurance provides additional options such as:
Treatment as a private patient in a public hospital. Medicare pays 75% of the Medical Benefits Scheme (MBS) costs and private health insurance pays the remaining 25%.
Treatment as a private patient in a private hospital. Private health insurance covers some or all of the costs for accommodation, theatre fees and specialist fees.
The advantages of private health cover
Advantages of private health cover over Medicare include the choice of your own treating doctor and eligibility for a shared or private room. Another advantage is shorter waiting times for elective (non-essential) surgery. While you can wait many months (sometimes years) in the public system for a procedure such as hip surgery, wait times are usually much shorter for private health fund members.
The other big advantage of private health insurance is extras cover for ancillary services such as optical, dental and physiotherapy, none of which are covered by Medicare. Because Medicare covers some out-of-hospital services not covered by private health insurance, such as GP visits and PBS pharmaceuticals, it can be a real advantage to have a combination of both private health insurance and Medicare coverage.
The amount Medicare pays toward your treatment varies based on where you are being treated:
Public Hospital
If you are treated in a public hospital, Medicare will pay 100% of the cost for the treatment itself, the anaesthesia, all diagnostic work like blood work and x-rays and all fees like theatre fees, accommodation fees and doctor's fees.
Private Hospital
If you are treated in a private hospital, Medicare will pay 75% of the public rate for the treatment, the anaesthesia and all diagnostic work. You and your health insurer are responsible for the rest, including 100% of the cost of all fees like accommodation fees, doctor's fees and theatre fees.
Outpatient Clinics
You might be treated in an outpatient for diagnostic work like X-rays, ultrasounds and blood work. Medicare will pay 85% of the public rate and you will be responsible for the rest. Private hospital insurance usually doesn't cover outpatient services.
General Practitioner
If you see a GP Medicare will pay 100% of the cost if the GP bulk bills. If they don't bulk bill, Medicare will pay 100% of the public rate and you will have to pay any extra if the doctor charges more.
Other Specialists
If you see a non-GP specialist, Medicare will pay 100% of the cost if the provider bulk bills. If they don't bulk bill, Medicare will pay 85% of the public rate and you will have to pay the additional 15% plus any extra if the doctor charges more.
Who is eligible for Medicare?
You are eligible for Medicare if you live in Australia or on an Australian dependency island such as Norfolk, Christmas and Lord Howe Island, though specific requirements and criteria apply. You must also be:
An Australian citizen. If you were born in Australia.
New Zealand citizen. You must have lived or intend to live in Australia for more than 6 months to be eligible.
An Australian permanent resident. If you have applied for your PR, or are disputing your PR, you are eligible for Medicare.
Living Overseas. You can also get access to Medicare if you're an Australian citizen and you live overseas. However, if you've been living overseas for more than 5 years you will no longer have access to Medicare.
How to claim Medicare benefits
You can generally claim Medicare benefits at the point of service. Most service providers have electronic claiming facilities, so they can lodge your claim on your behalf. If your GP or provider doesn't offer this,you'll need to claim your benefits in one of the following ways:
Using your Medicare online account through myGov
Using your Express Plus Medicare mobile app
Submitting a Medicare claim form by post, at your local service centre or at a participating private health insurer
Submitting a claim over the phone by calling Medicare
Other Medicare benefits
There are a few special Medicare benefits available for certain people. These include:
The Medicare Safety Net. This is available to all Australians with a Medicare card who exceed an annual threshold on the cost of their PBS pharmaceuticals. After the threshold is reached, you receive cheaper medicines for the remainder of the year. The threshold is considerably less for concession card holders.
Dental benefits under Medicare. There are benefits for basic dental services available for some children and concession card holders. Benfits for kids are capped at a little over $1,000 per child every two years. Services covered include examinations, x-rays, cleaning, fissure sealing, fillings, root canals and extractions. No benefit is payable for orthodontic or cosmetic dental work. Some state also have additional benefits on offer.
Pensioner medical equipment. Eligible pensioners can claim a payment towards the cost of eligible equipment such as home dialysis machines, home ventilators and respirators, oxygen concentrators, heart pumps, nebulisers, electric wheelchairs and insulin pumps.
Frequently asked questions
Yes. Medicare covers most medically necessary surgeries, and you can find a list of these on the Medicare Benefits Schedule (MBS). Since surgeries happen mainly in hospitals, Medicare will cover 100% of all costs related to the surgery if you have it done in a public hospital. This includes anaesthesia, diagnostic work and all fees. If you have it done in a private hospital, Medicare will chip in 75% of the public rate for the surgery, anaesthesia and diagnostic work. You and your private health insurer will be responsible for the rest including 100% of the fees.
Yes. Medicare will cover your specialist visits as long as a GP refers you and as long as it's a service listed on the MBS. This includes visits to dermatologists, psychiatrists, cardiologists and many others. If the specialist bulk bills, Medicare will cover 100% of the cost. If they don't bulk bill, Medicare will cover 85% of the public rate and you will be responsible for the additional 15% plus any private premium the specialist charges.
Yes. Medicare will pay for any anaesthesia that is part of a Medicare-covered surgery or treatment. It will pay 100% of the anaesthesia cost if the treatment is done in a public hospital leaving you with zero out-of-pocket expenses. Medicare will split the bill with your private health insurer if the treatment is done in a private hospital - although there may also be a gap that you'll have to pay yourself.
Medicare covers the X-rays a doctor needs to help them diagnose or treat an illness, as long as it is considered medically necessary in a public hospital. This also includes other types of medical imaging techniques like CT Scans and MRIs. The amount Medicare will pay depends on where you are treated:
In a public hospital. Medicare will pay 100% of the cost of your X-ray.
In a private hospital. Medicare will pay 75% of the public rate and your private insurer will pay the additional 25%. If the cost is higher than the public rate, you will be responsible for the difference.
In an outpatient setting. Medicare will pay 85% of the public rate and you will be responsible for the rest. Private health insurance doesn't usually cover outpatient services.
Just remember that Medicare doesn't cover most dental treatments, which includes X-rays related to dental work.
Tim Bennett is a Finder insurance & utilities expert. For over 10 years he's reported on news, politics, finance and other topics as a journalist and radio presenter. Tim's roles have included radio news reader and breakfast at the ABC, news producer for SBS and producer for Fairfax Media. Tim regularly appears as a health insurance expert on programs like Sunrise and SBS news, as well as in the Australian, The Daily Telegraph, The Courier Mail and more. See full bio
Tim's expertise
Tim has written 118 Finder guides across topics including:
Richard Laycock is Finder’s insights editor after spending the last five years writing and editing articles about insurance. His musings can be found across the web including on MoneyMag, Yahoo Finance and Travel Weekly. Richard studied Media at Macquarie University and The Missouri School of Journalism and has a Tier 1 Certification in General Advice for Life Insurance. See full bio
What is the Medicare Benefits Schedule (MBS) and what medical services does it cover? Find out in this comprehensive guide.
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