What Medicare Covers and How it Works

Australia's Medicare is a federal government-run marvel that provides free or low-cost basic medical and hospital care. It’s known as ‘universal healthcare’. It's for citizens, permanent residents, and some temporary residents.

What is Medicare?

Medicare is a catch all term for the Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS), and Medicare Safety Net. This blog just focuses on the MBS, the PBS will be covered separately soon – stay tuned.

In 2021-2022, there were 26.4 million of us enrolled in Medicare. This resulted in 511.5 million Medicare claims costing $29.1 billion (yes, with a B). It doesn’t cover everything, but it does make adulting well much cheaper and easier.

Lean into it folks!

What Medicare Covers (and doesn’t cover)

Medicare covers part or all of the costs for visiting your general practitioner and specialist appointments, some telehealth visits, tests and scans (like x-rays), medicines, most surgery and procedures performed by doctors, and eye tests by optometrists.

It won’t cover you for things like ambulance rides, visiting the dentist for anything, reading glasses, hearing aids or tweakments (cosmetic surgery).

How the Medicare Benefits Scheme (MBS) Works 

The MBS is a very long list of medical services, procedures, and tests, each with a unique code. These codes matter when you see your doctor or specialist for your surgery. They decide how much Medicare chips in for your care. It's like a passcode, ensuring you're not left with the whole financial load. From check-ups to procedures, the MBS has your back, making sure your health doesn't drain your funds.

Four ways you can find out what’s covered by the MBS:

1. MBS Online: Look up procedures or item numbers yourself by popping in the service name or number, and you'll find out what's covered and Medicare's contribution. Easy peasy!
2. Medicare Cost Finder: This is similar to the MBS search function, but more user friendly in my humble opinion.
3. Ask your doctor: Your doctor is familiar with the MBS and can guide you on what services are covered for your surgery.
4. Speak to Medicare: If you're unsure about a particular service, you can always call Medicare's helpline on 132011.

Bulk Billing

Bulk Billing is like a golden ticket for healthcare. When a doctor or specialist bulk bills, it means they accept the Medicare benefit as full payment for their services and $0 payment from you.

So, if you're bulk billed, you won't have to pay anything out of your own pocket. For someone going in for major surgery, bulk billing can take a load off your mind, as your medical expenses are taken care of by Medicare.

Search here Service Finder to find health professionals and services that Bulk Bill. Bulk billing doesn’t cover all health professionals or services. You need to do research on what your covered for based on your circumstances.

Partial Billing

This is when the doctor charges more than the Medicare benefit for their services. You'll need to pay the difference, known as the "gap”. The Medicare benefit will still cover a portion of the cost, but you'll have to contribute the rest. Some doctors choose to partially bill to reflect the true cost of their services or to provide extra services beyond what Medicare covers.

Treatment Plans

Medicare Plans are your savvy strategy for trimming health expenses while ensuring you receive necessary care. These plans maximise healthcare value and keep your budget in check.

Two plans that are good for people with chronic illness include:

1. Chronic Disease Management Plan: If you're dealing with ongoing health issues this plan is your financial ally. Your GP collaborates with Specialists to create a game plan that prioritises your health and manages costs. It's a personalised roadmap guiding you toward effective treatments without financial strain.
2.  Mental Healthcare Treatment Plan: For emotional wellbeing, this plan is your wallet-friendly ticket to prioritise mental wellness. It offers support and guidance without hefty bills. Subsidised sessions with mental health professionals provide help while minimising financial worry.

To tap into these plans, chat with your GP or Mental Health Professional.

Public Hospitals

If you're admitted to a public hospital, Medicare covers a significant portion of your medical expenses. In essence it should be free. This includes doctor's fees, diagnostic tests, and most medical services provided during your stay. Sometimes there may be some costs, which you should be told about beforehand.

Medicare Safety Net

The Medicare Safety Net's your back-up for covering costs outside of the hospital. It step in to help out when you've got hefty medical bills for stuff outside the hospital. Just remember, they won't kick in for things that aren't on the Medicare Benefits Schedule (MBS) or for MBS services done in a hospital.

When you hit a spending limit it kicks in to ease the load. Imagine facing piles of medical bills for your surgery because of extra blood tests or GP visits. Once you cross a certain point, the Safety Net steps in to cut your costs. No more feeling buried under bills – it's your safety cushion, keeping your finances steady.

The spending limit changes regularly. Here are some ways you can check the limit and how you’re tracking for the Medicare Safety Net.

1. Medicare Express Plus App
2. MyGov App
3. Call Medicare – 132 011

Who runs Medicare?

Services Australia runs the Medicare program. They manage Medicare enrolment, process Medicare claims, and provide information about Medicare benefits and services. They can help with Medicare-related queries, eligibility requirements, and provide guidance on accessing healthcare services under Medicare. Services Australia are the folks making sure all these payments get made.

Parting words

One more quick thing, all the parts under Medicare are a bit of a moving feast. They are regularly reviewed to keep up with medical innovation, the needs of Aussies, and many other factors. Some things are staples and unlikely to be changed, but specific medications discounted by the PBS may change or the rebate you get when seeing your GP might fluctuate.

P.S.

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