What’s not covered by Medicare?

What’s not covered by Medicare and the Pharmaceutical Benefits Scheme?

What’s not covered by Medicare?

Deciding between private health insurance and relying on the public health system mainly comes down to what’s covered by both schemes.

Australians young and old are lucky to have access to such a comprehensive public health system. Sure, you may have to wait for specialist services and assistance, but the fact that we do have access to such medical help is one of the reasons we can call Australia ‘the lucky country’.

Medicare covers you for most health and medical services, but there are some things you’ll have to pay for. That’s why it sometimes pays to have a combination of both private health and access to Medicare.

The latest Medicare Benefits Schedule Book released on 1 July 2018, includes the latest gap charges as well as the extra services covered by Medicare. At 1316 pages, it’s a comprehensive document and it contains all the services covered by Medicare.

Suffice to say, it’s a lot to cover, so to speak, but here’s a quick overview.

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

Medicare will cover you for any treatments in a public hospital where you’re treated as a public patient. You’ll not be charged, but you won’t be able to choose when you’re admitted, and your doctor will be appointed by the hospital. And you can be treated as a public patient, even if you have private health cover.

According to www.privatehealth.gov.au, Medicare will not cover you for:

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

When you visit a doctor outside of hospital, Medicare will reimburse 100 per cent of the Medicare Benefits Schedule (MBS) fee for a GP and 85 per cent of the MBS fee for a specialist. If your doctor bills Medicare directly (bulk billing), you will not have to pay anything.

Medicare will cover you for:

  • consultation fees for doctors and specialists
  • tests and examinations 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 dental surgery performed by approved dentists
  • specific items under the Cleft Lip and Palate Scheme
  • specific items under the Enhanced Primary Care (EPC) program
  • specified items for allied health services as part of the Chronic Disease Management Plan.

Medicare will not cover you for:

  • examinations for life insurance, superannuation or memberships for which someone else is responsible
  • 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
  • home nursing.

Under the Pharmaceutical Benefits Scheme (PBS) you’ll pay a part of the cost of most prescription medicines purchased at pharmacies when you produce your Medicare card. The rest of the cost is covered by the PBS. The gap cost will vary depending on the type of medicine.

The MBS and PBS are updated each year around Budget time, so if your required service or medicine is not currently on the list, contact your local Member or Senator and tell them it should be.

Do you mostly use Medicare, even if you have private health insurance? Are you happy with your private health cover? Is Medicare enough to ensure a worry-free retirement health-wise?



    To make a comment, please register or login
    Waiting to retire at 70
    24th Aug 2018
    It has been clear for a long time now that the problem with healthcare in this country has been a failure of care, conscious and governance. The medical profession is no different to the the financial sector, politicians, religions, charities, financial advisers, etc.

    No conscious, no governance, no care - 'dog eats dog' now reigns supreme. COMMUNITY has disappeared from the Australian landscape. Everything is about raking in the money. I don't want to live in an 'economic system', I want to live in a community.

    Telling us that the Medicare Benefits Schedule (MBS) fee for a GP is covered does not tell us the cost of a visit to a GP. When we're sick, who stops and ask how much the doctor charges and compares it with the MBS fee? We just want to be made well again. "Get them at their most vulnerable" seems to be their motto.

    Even my barber puts his fees up in his barber shop in clear site of his customers - they are required to do so by state regulation. Why aren't doctors made to do the same? Then we'll be able to make a choice, in advance, and have our choice, and every ones' choices, force practitioners to compete on cost, thus forcing down the gap.
    24th Aug 2018
    Re barber - they do? I never know what I might be charged. The same goes for car maintenance, legal fees, accountants,dentists etc. The numbers are all tallied but so very magical.

    24th Aug 2018
    Medicare converts all basic medical needs and more . It’s a wonderful system but an expensive one
    24th Aug 2018
    Unless you need dental care, glasses or an emergency dash to hospital.
    24th Aug 2018
    the ndis wants functional assessments but that ranges from 400.00 for physiotherapy assessments to 800.00 ++ for an occupational therapist but its not covered by medicare , how can those who need it afford it?? its bad enough that the NDIS isn't accepting so many disabilities calling them medical issues to avoid helping those suffering . go to community care they say, but com care doesn't provide what is needed
    24th Aug 2018
    This site is read by retired people and yet this article fails to mention that pensioners over 65 with a concession card or commonwealth seniors health card do not pay for ambulance services in NSW. An important omission, I believe.
    24th Aug 2018
    Thanks for that info.
    24th Aug 2018
    I understood Medicare had reciprocal agreements with New Zealand
    24th Aug 2018
    I have a friend who had emergency heart surgery. She has been in private health cover since she started wok at 15. Now in her Seventies she has a bill of thousands of dollars because of the gap. I can understand why people are opting out of health cover.

    Thank god I am covered by DVA.

    Its time to return to Medibank, we don't need a health cover who act for their investors.
    24th Aug 2018
    Why don’t we all pay $2500 each to the government to provide the same level of cover as private insurers
    Let’s see how long before the government ( especially labor governments) spend it all and the system goes back to the way it was
    80 plus
    25th Aug 2018
    olbaid, you just could not resist bringing in your misguided and incorrect political bias could you, an interesting discussion until you posting.
    Nose Hair Bob
    20th Dec 2018
    Membership fee to Ambulance Victoria
    Free cover for pensioners, low-income earners
    Call-out charge plus a per-kilometre charge
    Government subsidises 49 per cent of fee
    Fees ranging between $473 for patient transfer vehicle and $967 for life-threatening or urgent call-out
    Pensioners entitled to free service
    Membership fee to SA Ambulance
    Call-out fees up to $976, plus kilometre fee of $5.60
    Call-out fee and a per-kilometre fee
    Set call-out fees up to $959
    Free ambulance cover for pensioners
    Fees covered by State Government
    Fees covered by State Government

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