In Australia, Medicare benefits are payable under certain conditions, primarily for services that are considered clinically necessary. Here’s a summary of when Medicare benefits are typically payable:
- Consultations with Doctors: This includes visits to general practitioners (GPs) and specialists.
- Diagnostic Services: Tests and examinations ordered by a doctor, such as blood tests, X-rays, CT scans, and other diagnostic imaging and pathology services, are generally covered.
- Surgical and Therapeutic Procedures: Many procedures performed by doctors, whether in a hospital or a clinic, can be covered by Medicare. This includes both minor and major surgical procedures.
- Specific Allied Health Services: Under certain circumstances (like chronic disease management plans), services from allied health professionals such as physiotherapists, podiatrists, and dietitians may be covered.
- Eye Tests: Optometrist services, including standard eye tests, are typically covered.
- Prescription Medicines: Through the Pharmaceutical Benefits Scheme (PBS), Medicare provides access to prescription medicines at reduced costs.
- Mental Health Care: Medicare covers a portion of the cost for mental health services, including consultations with psychiatrists, psychologists, and other mental health professionals, under specific conditions.
- Dental Services for Children: Under the Child Dental Benefits Schedule, some dental services for eligible children aged 2-17 years are covered.
- Telehealth Services: Depending on the circumstances (such as during the COVID-19 pandemic), Medicare benefits have been extended to include telehealth services for a range of consultations.
Not Covered by Medicare:
- Most dental services for adults, cosmetic surgery, ambulance services, glasses and contact lenses, and hearing aids are not typically covered by Medicare.
- Most allied health services not covered under a Chronic Disease Management Plan or Mental Health Care Plan (ie the Better Access to Mental Health Scheme)
- Services for non-clinical purposes, such as pre-employment medicals, driving medicals, drug testing for employment, are also not covered.
- Note pre-employment medicals for unemployed people are covered by Medicare.
Additional Points:
- Bulk Billing vs. Patient Co-Payment: Doctors can choose to bulk bill a patient, meaning they accept the Medicare benefit as full payment for the service, or they may charge more than the Medicare rebate, in which case the patient pays the difference (known as a ‘gap’ payment).
- Referral for Alied Health Services: To receive Medicare benefits for allied health services, a referral from a GP is generally required as well as a GPMP or MHCP.
- Referral for Specialist Services: To receive Medicare benefits for specialist services, a referral from a GP is generally required, and this must pre-date the specialist service.