Medicare Summary from their Website
What does Medicare cover?
The benefits you receive from Medicare are based on a Schedule of fees set by the Australian Government. Doctors may choose to charge more than the Schedule fee.
Out-of-hospital services
Medicare provides benefits for:
- consultation fees for doctors, including specialists
- tests and examinations by doctors needed to treat illnesses, including X-rays and pathology tests
- eye tests performed by optometrists
- most surgical and other therapeutic procedures performed by doctors
- some surgical procedures performed by approved dentists
- specified items under the Cleft Lip and Palate Scheme
- specified items for allied health services as part of the Enhanced Primary Care (EPC) program—contact Medicare on 132 011 for more information
You can choose the doctor who treats you for out-of-hospital services.
In-hospital services
Public Patient
If you choose to be admitted as a public (Medicare) patient in a public hospital, you will receive treatment by doctors and specialists nominated by the hospital. You will not be charged for care and treatment, or after-care by the treating doctor.
Private Patient
If you are a private patient in a public or private hospital, you will have a choice of doctor to treat you. Medicare will pay 75 per cent of the Medicare Schedule fee for services and procedures provided by the treating doctor. If you have private health insurance some or all of the outstanding balance can be covered.
You will be charged for hospital accommodation and items such as theatre fees and medicines. These costs can also be covered by private health insurance.
What's not covered by Medicare?
Medicare does not cover such things as:
- private patient hospital costs (for example, theatre fees or accommodation)
- dental examinations and treatment (except specified items introduced for allied health services as part of the Enhanced Primary Care (EPC) program)—contact Medicare for more information
- ambulance services
- home nursing
- physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology
- acupuncture (unless part of a doctor's consultation)
- glasses and contact lenses
- hearing aids and other appliances
- the cost of prostheses
- medicines (except for the subsidy on medicines covered by the Pharmaceutical Benefits Scheme)
- medical and hospital costs incurred overseas
- medical costs for which someone else is responsible (for example a compensation insurer, an employer, a government or government authority)
- medical services which are not clinically necessary
- surgery solely for cosmetic reasons
- examinations for life insurance, superannuation or membership of a friendly society
You can arrange private health insurance to cover many of these services.
How do I claim from Medicare?
Bulk billing
You do not need to claim from Medicare as the doctor will bill Medicare directly.
Bulk-billing is when the doctor bills Medicare directly, accepting the Medicare benefits as full payment for a service. The doctor cannot make any additional charge for a service, nor can any other person or company. This means if the doctor bulk bills, you cannot be charged a booking fee, administration fee, a charge for bandages, record keeping or a charge by the doctor’s company.
Most doctors’ bulk bill some of their patients, such as pensioners or health care cardholders. You will be asked to sign a completed form after the service if the doctor bulk bills. You must always be given a copy of the completed form.
There are circumstances where more than one service can be provided at the same visit and the doctor is not required to bulk bill in respect of each service.
How is my Medicare rebate calculated?
When Medical services are provided outside hospital, Medicare usually pays 85 per cent of the Schedule fee other than for GP services. The patient pays the difference between the Schedule fee and the rebate (known as the 'gap'), plus the difference between the Schedule fee and the practitioner's charge (if the practitioner decides to charge above the schedule fee).
The Schedule fees are uniform across Australia and are determined by the Department of Health and Ageing in consultation with professional bodies. Medicare benefits are based on a percentage of the Schedule fee for each service as listed in the Medicare Benefits Schedule. Practitioners are able to charge fees they consider suitable for the services they provide, however, any extra amount about the Schedule fee will not be included in the calculation of Medicare benefits.
How does the Medicare Safety Net work?
If you need to see a doctor or have tests regularly you could end up with high medical costs. The Medicare Safety Net is designed to help you when you need it most. It means that once you reach a safety net threshold, visits to your doctor or having tests may end up costing you less.
All families and couples need to register. Even if all your family members are listed on your Medicare card you still need to register for the safety net.
- each family member needs to be identified so their medical costs can be counted toward your family’s safety net.
- you only need to register your family once.
- registering is free.
Please note: if you are registered as a family for safety net purposes, you must confirm your family make-up in writing each year with Medicare before any safety net benefits can be paid for services not already claimed.
Individuals are automatically registered—just keep your contact details up-to-date with Medicare.
Individuals, families and couples are all eligible for the same threshold amounts. If you register as a family or couple your medical costs are combined so that you are more likely to reach the thresholds sooner.
Medicare Safety Net thresholds as at January 2006
Threshold / Who it is for? / How it is calculated? / Benefit to youGap / $345.50* / All Medicare card holders / Based on gap amount / 100% of Schedule fee for out-of-hospital services
Concession and Family Tax Benefit (Part A) {FTB(A)} / $500.00* / Commonwealth concession card holders
Families eligible for FTB(A) / Out-of-pocket costs / 80% of out-of-pocket costs for out-of-hospital services
General / $1000.00* / All Medicare card holders / Out-of-pocket costs / 80% of out-of-pocket costs for out-of-hospital services
* These amounts are adjusted annually.
Out-of-pocket costs —the difference between the Medicare benefit and what your doctor charges you.
Gap amount —the difference between the Medicare benefit and the Schedule fee.
Schedule fee —a fee for service set by the Australian Government.
What is the PBS?
Many types of medicine cost much more than the price you pay - some cost hundreds of dollars. The Government pays most of it for you. The Government does this through the Pharmaceutical Benefits Scheme (PBS).
How much will I pay?
PBS contribution amounts as at 1 January 2006:
General patients / $29.50*Concession card holders / $4.70*
DVA / $4.70*
If you have a DVA White Card for specific conditions accepted by DVA you will pay $4.70, otherwise you pay the general amount.
* These amounts are adjusted annually and do not cover additional costs on more expensive brands of medicine.
Please note, if you choose a more expensive brand of medicine, or if your doctor prescribes one, the extra amount you pay won’t count towards your PBS Safety Net.
Who is eligible for the PBS?
- all Australian residents
What is the PBS Safety Net?
If you or your family need a lot of medicine in a calendar year, the PBS Safety Net helps you with the cost of medicine. Once you or your family reach a Safety Net threshold, you can apply for a PBS Safety Net card - your PBS medicine will be less expensive (or free) for the rest of the calendar year.
What do I have to do?
Keep a record of your PBS medicine on a prescription record form which you can get from your pharmacy. Each time you have a PBS medicine supplied, hand your prescription record form to the pharmacist so the supply can be recorded. Your pharmacy might be able to keep a record for you on their computer, but if they can’t or you visit different pharmacies its best to keep your own records. If you have a family, ask your pharmacy about combining the amounts you spend for your Safety Net total.
When you are close to reaching the Safety Net threshold, talk to your pharmacist about how you can apply for a Safety Net card. When your pharmacist has issued your Safety Net card, medicine will be cheaper or free for the rest of the calendar year.
To apply for your PBS Safety Net card talk to your pharmacist.
PBS Safety Net thresholds as at 1 January 2006
PBS Safety Net threshold / PBS Safety Net contributionGeneral patients / $960.10* / $4.70*
Concession card holders / $253.80* / Free*
* These amounts are adjusted annually and do not cover additional costs on more expensive brands of medicine.
What if I’ve got a non-PBS prescription?
Your doctor might give you a prescription for a medicine that isn’t available on the PBS, or isn’t available on the PBS for your condition – sometimes called a ‘private prescription’. Your doctor will indicate this on your prescription and you will need to pay the full price for the medicine at the pharmacy. The cost of these prescriptions does not count towards your PBS Safety Net.