Understanding What Medicare Covers
Medicare is Australia's universal public health insurance scheme, designed to give all eligible Australians access to affordable medical care. However, it doesn't cover everything. Knowing what's included — and what isn't — helps you plan your healthcare and avoid unexpected out-of-pocket costs.
Services Medicare Does Cover
General Practitioner (GP) Visits
Medicare subsidises visits to GPs who are registered with Medicare. If your GP bulk bills, you pay nothing out of pocket. If they charge above the Medicare Benefits Schedule (MBS) fee, you pay the difference — known as a "gap" payment.
Specialist Consultations
Referrals from a GP to a specialist (e.g., cardiologist, dermatologist, or orthopaedic surgeon) are covered under Medicare at a set rebate rate. Specialists often charge above the schedule fee, so gaps are common.
Public Hospital Treatment
As a public patient in a public hospital, you can receive treatment at no cost. This includes surgery, emergency care, nursing, and most allied health services provided during your stay.
Diagnostic Tests and Imaging
Medicare covers a significant portion of costs for pathology tests (blood tests, biopsies) and diagnostic imaging (X-rays, ultrasounds, MRIs) when ordered by a doctor.
Mental Health Services
Through the Better Access initiative, people with a Mental Health Treatment Plan from their GP can access up to 10 subsidised sessions per calendar year with a psychologist, social worker, or occupational therapist.
Preventive Health Services
Medicare funds several national screening programs, including:
- Bowel cancer screening (for eligible age groups)
- Breast screen Australia (mammograms)
- Cervical screening
- Health assessments for people over 75
Services Medicare Does NOT Cover
| Service | Covered by Medicare? |
|---|---|
| Dental treatment | Generally not (exceptions for children via CDBS) |
| Optical (glasses, contact lenses) | No |
| Physiotherapy (private referral) | No |
| Cosmetic surgery | No |
| Ambulance services | No (covered by state schemes or private insurance) |
| Overseas medical costs | No |
The Medicare Benefits Schedule (MBS)
The Medicare Benefits Schedule (MBS) is the official list of health services subsidised by Medicare. Each service has an item number and a set fee. Medicare typically pays 85% of the schedule fee for out-of-hospital services and 75% for in-hospital services (as a private patient).
Do You Need Private Health Insurance?
Medicare is comprehensive for essential health services, but many Australians choose to supplement it with private health insurance to cover dental, optical, physio, and private hospital accommodation. Whether this is right for you depends on your health needs and financial situation.
Summary
Medicare provides solid foundational health coverage for all eligible Australians. It works best for GP care, specialist referrals, diagnostic services, mental health support, and public hospital treatment. For anything outside these areas, you'll likely need to budget for out-of-pocket costs or consider additional private coverage.