What does Medicare cover in Australia?

Disclaimer: The content of this blog is for informational purposes only and does not replace professional medical diagnosis, advice, or treatment.

Overview

Medicare is a government-funded system that enables all citizens and permanent residents to access essential medical care and hospital services, regardless of their ability to pay. It is partly funded by the Medicare Levy, which is charged to tax paying individuals. Depending on the type of medical care provided, the service may either be fully or partially covered by Medicare.

How does Medicare work?

The Medicare Benefits Schedule (MBS) lists each health services that attracts Medicare funding, and how much funding is allocated. If the healthcare provider charges more than what Medicare will fund  the patient will be required to pay the difference ( the “gap fee”). Public hospitals typically have no gap fee for patients, either as an inpatient or outpatient. Services Australia automatically tracks individuals out-of-pocket expenses. A couple or a family often register as a "Safety Net family" so the combined out-of-pocket costs count. Once an individual or family spend a certain amount in a calendar year, Medicare pays a higher rebate for the remainder of the year. The Pharmaceutical Benefits Scheme (PBS) reduces the cost of many prescription medicines, so the patient will only pay a standardised amount, regardless of the type of medication.

How to access Medicare

Individuals must make an application directly to Medicare, and then one of the following will be issued;

1. Green Medicare cards are issued to Australian citizens, permanent residents and eligible New Zealand citizens.
2. Blue Medicare cards are only given to certain special visa holders, or those temporary residents who have applied for and are awaiting permanent residency to be granted. It provides the same Medicare benefits as the green card.
3. Yellow Cards are issued to visitors from countries that have a Reciprocal Health Care Agreement with Australia. It only covers medically necessary or immediate medical care for the duration of the individual’s stay.

Doctors consultations and Medicare rebates

Each Doctors or medical practitioner service provider will decide if they will charge a gap fee or not. If a gap fee is not charged, this is usually referred to as “bulk billed*”. For face-to-face consultations, the amount rebated by Medicare depends on the duration of the consultation. The rebated amount also alters depending on whether the consult takes place within “antisocial hours” or not (eg – evenings, overnight or weekends).  

Consult Level	Duration
Level A	Under 6 minutes
Level B	6-20 minutes
Level C	20-40 minutes
Level D	40+ minutes

Telephone and video GP consults (“telehealth”) also attract Medicare rebates. However, if a patient does not have an established face-to-face relationship with that particular GP and/or the GP clinic, Medicare rebates for telehealth do not apply. If you have a diagnosed mental health condition, a GP can create a Mental Health Care Plan (MHCP). This plan enables Medicare rebates for up to 10 individual sessions with a psychotherapist each year. An initial referral is often provided for up to 6 sessions. After a GP review, the remaining sessions can be provided if still clinically indicated. Some GP services are private and are not covered at all by Medicare rebates.

Specialist appointments

A GP will need to write a referral letter to a private specialist to enable Medicare rebates for the specialist appointment. A referral is usually valid for 12 months. To see a specialist at a public hospital for the first time, a GP referral is also required to be allocated an appointment by the hospital. To see an allied healthcare professional (eg – physiotherapy, podiatry), a referral is not necessary. However, if you have a chronic health condition (expected to last 6 months or longer) then the GP can create a GP Chronic Conidition Management Plan (GPCCMP) which can provide patients with medicare rebates for six allied healthcare sessions each calendar year. Medicare does not provide rebates for dental care, hearing aids or cosmetic procedures. Note: Specialist and allied health services are not provided directly by Hola Health. Information regarding these rebates is for educational purposes only.

Pathology tests and diagnostic imaging covered by Medicare

Medicare covers the full cost of most pathology tests (eg – blood tests, urine tests etc.) with a referral from There are many providers that offer imaging services (eg – X-rays, ultrasounds, CT and MRI scans etc.) and their policies for gap fees will vary. The GP may be able to guide their patients on possible out of pocket expenses, but it is advisable to contact the imaging service providers directly. Note: CT and MRI referral services are not provided directly by Hola Health and are included for informational purposes only.

How Hola Health can help?

Hola Health can help 24/7 with:

• Online doctor consultations
• After-hours doctor consultations 
• Medical cert (subject to clinical assessment)
• Specialist referrals
• Pathology request forms
• Prescription medication (if clinically appropriate)

Hola Health offers telehealth consults across Australia. Bulk billing* is available for eligible patients with a valid Medicare card for after-hours urgent care during designated periods only: 11pm to 6:45am, 7 days a week. After-hours telehealth is designed for emergency but non-life-threatening conditions when your regular GP or clinic is closed. It is not a substitute for emergency care. If you experience severe, worsening, or life-threatening symptoms, call 000 immediately or attend your nearest Emergency Department (ED). Examples include chest pain, breathing difficulties, stroke symptoms, or severe allergic reactions.