How does Medicare work?

As Australia’s public health care scheme, Medicare pays for some of the costs of your health care.

It does not pay for all the costs of the medical services you use.

How to access Medicare  

To access Medicare, you need to be eligible to enrol.

When you enrol, you receive a Medicare Card. It looks like this:

You also receive a My Health Record, which stores all your health data in one place.

What does Medicare cover?  

Medicare covers the costs of part or all of these services:

• hospital treatment at a public hospital by a doctor appointed by the hospital
• out-of-hospital services provided by general practitioners (GPs) and specialists
• some tests and scans such as x-rays
• some prescription medicines
• eye tests by optometrists.

Medicare does not cover:

• private patient hospital costs
• ambulance services
• most dental services
• most allied health services such as physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic, podiatry and psychology services.

The Medicare Benefits Schedule (MBS) provides a detailed list of services, which is managed by the Australian Department of Health.

Will Medicare pay if I see a GP?  

Yes. If you are enrolled with Medicare, it will pay some or all of the costs when you visit a GP.

If your GP chooses to bulk bill, Medicare covers 100% of the cost of their service. You do not have to pay for the service.

If your GP does not bulk bill, you need to pay:

• the full cost of the service or
• the difference between the rate they charge and what Medicare covers.

If you pay the full cost, you can claim the amount Medicare covers by:

• making a claim or
• asking your doctor to make a claim on your behalf.

Will Medicare pay if I see a specialist?  

Yes. If you are enrolled with Medicare, it will pay some or all of the costs of you seeing a specialist. 

If your specialist chooses to bulk bill, Medicare covers 100% of the cost and you do not have to pay for the service.

If your specialist does not bulk bill, Medicare pays 85% of the scheduled fee and you have to pay the remaining 15% plus any additional amount the specialist charges.

Will Medicare pay if I use telehealth to see a GP? 

Medicare will pay for some or all of your telehealth consultation with a GP if it meets all these criteria:

• There is an MBS telehealth item number for the service you are receiving.
• It must be safe and clinically appropriate for the GP to conduct the consultation via telehealth.
• You must have an established clinical relationship with the GP, which means you have had at least one face-to-face consultation with that GP in the previous 12 months or the GP must be working in a practice where you have had at least one face-to-face service arranged by that practice in the previous 12 months.

There are some exceptions to the ‘established clinical relationship’ requirement. This means your GP can provide you with a telehealth consultation even if you have not had a face-to-face consultation in the past 12 months, if you are:

• a child under 12 months
• homeless
• receiving an urgent after-hours service
• a patient of a doctor at an Aboriginal Medical Service or Aboriginal Community Controlled Health Service
• isolating because of a COVID-related State or Territory public health order or in COVID-19 quarantine because of a State or Territory public health order.
• living in a flood-affected area, currently declared as a natural disaster area due to flood by a State or Territory Government
• a patient accessing specific MBS services for:
  • blood-borne viruses, sexual or reproductive health consultations
  • pregnancy counselling services
  • mental health services
  • nicotine and giving up smoking counselling.

Contact your GP directly to find out whether they provide telehealth and whether you are eligible for a consultation. 

Will Medicare pay if I use telehealth to see a specialist? 

Medicare will pay for some or all of your telehealth consultation with a specialist if it meets the following criteria:

• There is an MBS telehealth item number for the service you are receiving.
• It must be safe and clinically appropriate for the specialist to conduct the consultation via telehealth.

Specialists most often use telehealth for patients living in regional or rural areas.

Contact your specialist directly to find out whether they provide telehealth and whether you are eligible for a consultation. 

Will Medicare pay all or part of the cost if I go to hospital?  

Will Medicare pay if I go to a public hospital in an emergency? 

Yes. If you are enrolled in Medicare and you attend a public hospital emergency department, it will cover your hospital costs. If you are seriously ill or badly hurt and go to a public hospital emergency department, Medicare will cover the cost of your treatment.

Will Medicare pay if I go to a public hospital because I am referred by a specialist? 

Yes. If your GP refers you to a specialist and the specialist recommends you need hospital treatment, Medicare will cover the cost of your treatment when you go into a public hospital as a public patient. You may have to wait to go into hospital if the treatment is not urgent. 

Will Medicare pay any of the cost if I go to a private hospital? 

Yes. If you are treated in a private hospital, Medicare will pay 75% of the scheduled fee for:

• treatment
• anaesthesia
• all diagnostic work.

You or your insurer are responsible for the remaining 25% of the cost of treatment, anaesthesia and diagnostic work.

You or your insurer must pay 100% of the accommodation fees, doctors’ fees and theatre fees.

Will Medicare pay any of the cost if I go to an outpatient clinic?

Yes. For diagnostic work like x-rays, ultrasounds and blood tests, Medicare pays 85% of the scheduled fee and you are responsible for the rest.

In most cases, private Hospital Cover does not cover outpatient services.

Will Medicare pay for an ambulance?  

No. Medicare does not cover the cost of ambulance services to hospital.

Ambulance costs vary between states and territories.

If you live in a state where you are not entitled to free ambulance treatment or transport and you want to be covered, you can buy Ambulance Cover from a private health insurer.

Will Medicare pay for the cost of my medicines? 

The Pharmaceutical Benefits Scheme (PBS) helps you get PBS medicines at a cheaper price.

You may get additional discounts if you hold a:

• Concession Card
• Health Care Card.