Overview of Health System

Medicare is a universal health care system that delivers affordable, accessible and high-quality health care for most Australian residents. You can also choose to take out private health insurance to give you more health care options and to cover items which are not covered by Medicare.

You can get a Medicare card if you live in Australia or Norfolk Island and meet certain criteria. You may also be eligible for a Medicare card if you visit from certain countries. 

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Medicare is a universal health care system that delivers affordable, accessible and high-quality health care for most Australian residents. You can also choose to take out private health insurance to give you more health care options and to cover items which are not covered by Medicare.

You can get a Medicare card if you live in Australia or Norfolk Island and meet certain criteria

You may be eligible for a Medicare card if you visit from certain countries. You should note that some limits may apply. If you are visiting from overseas and are a reciprocal Medicare card holder, see Overseas visitors & overseas students health cover.

Below is a summary of what is covered by private health insurance and Medicare for hospital, medical services and general treatment, pharmaceutical benefits and ambulance.

Hospital

Private CoverMedicare

Provided your policy covers the service that is being treated in hospital: 

You can choose to be treated as a private patient in either a public or a private hospital.

You can choose your own doctor. On most policies you can decide whether you will go to a public hospital, or a private hospital which has an agreement with your insurer. You may also have more choice as to when you are admitted to hospital. 

If you are a private patient in a public hospital, public hospital waiting lists still apply.

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 can be treated as a public patient in a public hospital by a doctor appointed by the hospital.

You cannot choose your own doctor and you may not have a choice about when you are admitted to hospital.

You can choose to be treated as a public patient even if you are privately insured.

The remaining hospital and medical costs will be charged to you - some or all of these costs may be covered by your private health insurance, depending on your policy.

The remaining costs include 25% of the MBS fee for doctors' services and any amount the doctors charge above the MBS fee, 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.

As a public patient you will be treated at no charge.

Medicare does not cover:

  • 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; and
  • examinations for life insurance, superannuation or memberships for which someone else is responsible (for example, a compensation insurer, employer, or government authority).

For further information please see:

Medical Services and General Treatment

Private CoverMedicare
If 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 - this applies whether or not you hold private health insurance. If your doctor bills Medicare directly (bulk billing), you will not have to pay anything.

Medicare does not provide benefits for the following:

  • 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; and 
  • home nursing.

You can arrange private health insurance to cover many of these services. Most insurers will have limits on how much you can claim per service and per year.

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 in public hospitals;
  • 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; and
  • specific items for allied health services as part of the Chronic Disease Management Plan.

For further information please see:

Pharmaceutical

Private CoverMedicare

Under the Pharmaceutical Benefits Scheme (PBS), you pay only part of the cost of most prescription medicines purchased at pharmacies in Australia. 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 Government-issued concession cards have a lower maximum payment.

You can arrange private health insurance to cover many prescription medicines which aren't listed on the PBS. Most insurers will require you to make a co-payment towards the cost and will have limits on how much you can claim.Some prescription medicines are not listed on the PBS. You pay the full amount for these non-PBS items.

Ambulance

Private CoverMedicare
In Queensland and Tasmania, emergency ambulance services are provided to residents for free by the State Government. 
New South Wales and Australian Capital Territory provide free emergency ambulance services for Pensioners and Concession Card Holders.
In the Northern Territory, NT Centrelink Pensioner Concession Card or Health Care Card holders are exempt from ambulance fees.
Victorian Pension Concession/Healthcare Card holders are also covered for clinically necessary ambulance transport but Commonwealth Seniors Health Card holders are not covered.
If you do not fall into any of the above categories above you can arrange ambulance cover from the ambulance authority in your state or territory, or from a health insurer.Medicare does not cover the cost of emergency or other ambulance services.

For further information please see: