What does Medicare not cover?
Answering all your big Medicare questions
Medicare is Australia’s national healthcare system. It is run by the Australian Government and funded by Australian taxpayers. Understanding what costs Medicare covers can help you on your health journey.
If you’ve registered for a Medicare card, you’ll get access to free or low-cost care for certain illness and injuries that might lead to hospital, medical and pharmaceutical costs.
It can be hard at times to work out what Medicare covers and how much is covered, as well as the services not covered by Medicare, says Shaun Bowden, nib’s Group Manager, Clinical Risk and Quality.
“It’s important to remember that Medicare provides a contribution,” he says. “It will cover some of the cost, but it may not cover all of it.”
How is Medicare coverage decided?
Shaun notes that even though you may see news reports about cutting-edge medical techniques, the committee might not always assess these techniques as suitable for the MBS.
What does the government cover?
Medicare generally covers treatments that are “medically necessary”, Shaun notes. If there’s any doubt if a procedure is medically necessary, the medical professional treating you will make that call. Australians also have access to government-funded public hospital system.
Broadly, Medicare and the public hospital system will cover some of the costs of:
This includes seeing a doctor, specialist and other health professionals (including tests, scans and x-rays). If your doctor or GP bulk bills, you won’t have to pay for anything. This includes medical services received in a hospital whether you are admitted as a public or private patient, and covers most surgery and procedures performed by doctors in both public and private hospitals.
The public hospital system covers the hospital costs of public patients in public hospitals. The hospital costs for private patients in private hospitals are covered by the patient’s private health insurance, but there may also be some out-of-pocket expenses that the patient will have to pay.
Medicines listed on the Pharmaceutical Benefits Scheme (PBS) are subsidised by the Australian Government.
Mental health care
Medicare covers treatment through the Mental Health Treatment Plan (up to a set amount of sessions) with a mental health professional.
What about coverage for children?
Medicare provides some extra cover for children. This includes cover for childhood immunisations, the cost of services needed by children with disabilities, and help with cleft lip and palate treatment.
The Child Dental Benefits Schedule also fully covers eligible children under 18 for some basic dental work, including check-ups, cleaning, x-rays, fissure sealing, fillings, root canals and extractions.
“However, this doesn’t cover most orthodontic work,” Shaun notes.
Is pregnancy and fertility treatment covered?
Pregnancy and birth
Medicare will help with the cost of:
some immunisations, and
care from midwives and obstetricians.
If you give birth in a public hospital, you won’t have to pay for the birth.
If you give birth in a private hospital, your private health insurance will cover some of the costs, but you may also have out-of-pocket expenses, depending on your level of cover and waiting period.
Fertility treatment and IVF
Medicare can help cover some of the costs for fertility treatments and assisted reproductive treatments, such as IVF. Registering for the Medicare Safety Net will help reduce out-of-hospital costs once the threshold is met.
Shaun notes that because fertility treatment can sometimes be a long journey, it’s important to talk to your doctor, the specialist clinic and your insurer to find out what is covered and what’s not.
What is not covered under Medicare?
Medicare does not cover the following expenses but may cover some of the services related to them. For example:
Medicare does not cover ambulance trips, although Queensland residents, Tasmanian residents and pension and healthcare card holders have ambulance services provided through state ambulance schemes. The good news is that all our covers include unlimited emergency ambulance, excluding DentalPass and members covered by state ambulance schemes.
Most dental services for adults – Many Australians look to private health to fill this gap.
Glasses, contact lenses and hearing aids – However Medicare does cover eye tests.
Cosmetic surgery – Although Medicare can cover the cost of complications that arise from the cosmetic surgery.
Ask for clarity to avoid “bill shock”
When a health professional recommends treatment for you, Shaun recommends asking them for a clear breakdown about who pays for what.
“You need to ask your doctor up front – what’s covered? What’s my private health paying for? Are there any out-of-pocket expenses?”
And if they recommend treatment that includes out-of-pocket expenses, Shaun says you don’t have to automatically accept this recommendation.
“There’s no shame in getting a second opinion, especially if you’re not clear about out-of-pocket expenses and what your alternatives are,” he says. “Yes, it may cost you again to see another specialist, but it may also save you or reassure you.”
Please note: The tips throughout this article serve as broad information and should not replace any advice you have been given by your medical practitioner.
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As Group Manager of Clinical Risk and Quality at nib, Shaun Bowden spends a lot of time going through information with a fine-toothed comb. A trained health professional and educator, Shaun has a knack for translating metrics, policies and standards so they can be put into practice effectively, meaning nib members can get the best health outcomes possible. Shaun’s past roles include assisting patients in clinical trials of new drugs and being a lecturer at Flinders University. Shaun’s top tip for a crusty bread loaf when baking is to throw a couple of ice cubes into the bottom of the oven.