Understanding Medicare Benefits
Medicare benefits are the subsidies the Australian Government pays toward the cost of eligible medical services. These benefits are determined by the Medicare Benefits Schedule (MBS) — a comprehensive list of medical procedures, consultations, and tests that Medicare will help fund.
For each item on the MBS, there is a set "Schedule Fee." Medicare pays a rebate based on a percentage of that fee. The gap between what Medicare pays and what a provider charges is what you pay out of pocket — unless your provider bulk bills.
GP and Primary Care Services
General Practitioner (GP) consultations are one of the most commonly used Medicare benefits. When your GP bulk bills, you pay nothing. When they don't bulk bill, Medicare still covers a rebate — typically 100% of the MBS Schedule Fee for GP services — but you'll pay any amount charged above that fee as a gap payment.
Medicare covers various types of GP consultations, including:
- Standard consultations (short, standard, and long)
- After-hours consultations
- Telehealth (phone or video) consultations
- Health assessments (e.g., 45–49 year old health checks, over-75 assessments)
Specialist Services
To see a Medicare-covered specialist, you generally need a referral from your GP. Medicare pays 85% of the MBS Schedule Fee for specialist consultations. If treated as a private patient in a public hospital, Medicare covers 75% of the MBS fee.
Covered specialists include cardiologists, dermatologists, orthopaedic surgeons, ophthalmologists, psychiatrists, and many more.
Pathology and Diagnostic Imaging
Medicare covers a wide range of diagnostic services, including:
- Pathology: Blood tests, urine analysis, biopsies, and other laboratory tests ordered by your doctor
- Diagnostic imaging: X-rays, ultrasounds, CT scans, MRIs (for specific conditions), and nuclear medicine scans
Many pathology providers bulk bill, meaning no out-of-pocket cost to you. Imaging services may or may not bulk bill depending on the provider and the specific test.
Mental Health Services
Australians with a diagnosed mental health condition can access Medicare-subsidised psychological services through a Mental Health Treatment Plan (previously called a Mental Health Care Plan), prepared by their GP.
Under this plan, eligible individuals can access:
- Up to 10 individual sessions per calendar year with an eligible psychologist or mental health professional
- Up to 10 group therapy sessions per calendar year
Medicare pays a rebate for each session. Psychologists may charge above the rebate amount, resulting in a gap fee.
Chronic Disease Management
People with chronic or complex medical conditions can access Medicare's Chronic Disease Management (CDM) plans, previously known as Enhanced Primary Care plans. These allow GPs to coordinate care with allied health professionals such as physiotherapists, dietitians, and podiatrists — with Medicare covering a rebate for up to 5 allied health sessions per calendar year.
Hospital Services (as a Public Patient)
If you're admitted to a public hospital as a public patient, Medicare covers:
- Hospital accommodation
- Nursing and medical care
- Surgeries and procedures performed by hospital-appointed doctors
- Medications administered during your hospital stay
As a public patient, you cannot choose your own specialist — you are treated by the hospital's medical team.
Services Medicare Does NOT Cover
Understanding the gaps is just as important. Medicare does not cover:
- Most dental services (except limited emergency dental for concession holders)
- Ambulance transport
- Optical services (glasses, contact lenses)
- Cosmetic procedures
- Most physiotherapy, chiropractic, and remedial massage without a CDM plan
- Overseas medical costs
Quick Reference: Medicare Rebate Rates
| Service Type | Medicare Rebate |
|---|---|
| GP consultation (out-of-hospital) | 100% of MBS Schedule Fee |
| Specialist consultation (out-of-hospital) | 85% of MBS Schedule Fee |
| Private patient in public hospital | 75% of MBS Schedule Fee |
| Pathology | Varies; often bulk billed |
| Mental health sessions (under care plan) | Set rebate per session (MBS listed amount) |
Knowing what Medicare covers — and where the gaps are — helps you plan your healthcare spending and decide whether private health insurance might be worth considering.