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Medicare – How It Works And What You Need To Know

Jonathan October 13th, 2015 0 comments

Medicare provides free or discounted access to medical and hospital treatment and care as a public patient. It works on the basis that everyone makes at least a small contribution to the scheme through taxes and the Medicare levy.

Who is Eligible?

You’re eligible for Medicare benefits if you’re an Australian or New Zealand citizen or hold a permanent visa. You  may also be eligible if you’ve applied for a permanent visa, although other criteria need to be fulfilled too. Medicare is also available on a more restricted basis to foreign visitors who come from a country with which Australia has a Reciprocal Health Care Agreement.

How to Register

To be eligible for Medicare benefits, you need to complete an enrollment form. This can be found on the Medicare Australia website or at your local Medicare office. You’ll need a birth certificate or passport to prove that you qualify.

What Is Covered?

As a public patient: For hospital treatment, you aren’t required to pay for treatment or aftercare but you have no choice regarding who treats you as the doctor or specialist is nominated by the hospital. As a public patient, you can also be covered for non-medical treatment such as:

  • Consultation fees with doctors or specialists
  • Diagnostic tests such as X-rays
  • Eye tests
  • Most surgical treatments performed by a doctor
  • Some surgical treatments performed by an approved dentist

As a private patient: While you have greater control over who treats you, you’re only covered for 75 per cent of the Medicare Schedule fee for treatments and services provided by the doctor or specialist in question with the remaining 25 per cent often being partly or fully covered by private health insurance. You’re also charged for things like hospital stays, theatre fees and medication, which can also be settled through private health insurance.

What Isn’t Covered?

Not all treatments and services are available through Medicare and you’ll need to arrange private health insurance to cover them. Some of these include:

  • Most dental examinations and treatment
  • Ambulance travel
  • Physiotherapy and occupational therapy
  • Speech therapy
  • Eye therapy
  • Chiropractor treatments
  • Podiatry treatments
  • Psychological treatments
  • Acupuncture (unless the treatment is part of a consultation
  • Glasses and contact lenses
  • Hearing aids
  • Medicines (excluding those that are covered by the Pharmaceutical Benefits Scheme
  • Overseas medical and hospital costs unless these are incurred in a country with which Australia has a Reciprocal Health Care Agreement
  • Medical treatment that isn’t deemed strictly necessary such as cosmetic surgery for vanity purposes

Making a Claim

When it comes to claiming Medicare benefits, there are several options available to you, including:

Claiming at the surgery. If your doctor’s surgery offers electronic claiming, you can take advantage of this for convenient claims. This option usually takes two to three days for the money to arrive in your nominated bank account. You’ll need your Medicare card (and EFTPOS card if the surgery uses this method of electronic claiming) card with you at your appointment to make claims at the surgery.

At your local Medicare office. You can make your claim in person or use the drop box facility at your nearest Medicare office.

At Medicare Australia Access points. For those who can’t get a local Medicare office easily, Medicare Australia access points can be found in some pharmacies, rural transaction centres and shops. This option works in a similar fashion to claiming by phone in that your claim will be discussed and the claim process will be begin but you’ll still need to send your receipts and/or account to Medicare Australia before you can receive payment (see the ‘By mail’ paragraph for where to send). You can search for your nearest access point here.

Using the Online Services. Depending on what you’re claiming for, you may be able to use the Online Services to make your request and as with claims made at your doctor’s surgery, you should receive the money into your nominated bank account within two to three days. There are limits on how much you can claim for, which is set at a maximum of $250 per day up to $550 per month (which is classed as a 30-day rolling pattern). For more information on making Medicare claims online, there are FAQs and tutorials available on the Medicare Australia website. If you’re not sure whether you can make your claim online, you can use the ‘Check item number’ tool on the Medicare Australia website to check.

By mail. You can download the Medicare claim form from the Medicare Australia website (along with receipts and the original accounts) and address it to Medicare Australia, GPO Box 9822, [your capital city]. You can receive your Medicare benefit paid into your nominated bank account or as a cheque once your claim has been processed.

By phone. If you’d prefer to make a claim over the phone, you can give your claim details by calling 1300 360 460. You don’t need to send a Medicare claim form but you do still need to send receipts (and account, if this is applicable) to Medicare Australia (see the ‘By mail’ paragraph above for where to send). How quickly your claim is processed depends on whether or not your account is fully paid up. If it is and you’re claiming for less than $100, you can expect to receive your payment in one to three days after phoning. Otherwise, your receipt and/or account needs to be received before your claim is processed and you’ll then be sent a cheque made payable to your health professional, which you need to send on.

Through participating health funds. If you’re a member of a participating health fund, you can complete a Medicare claim form and make your claim through them. Attach receipts and/or accounts to the form (see the ‘By mail’ paragraph for where to send). Alternatively, you can fill in a two-way Medicare claim form, attach the receipts and/or accounts and make your claim at your local Medicare office (see the ‘At your local Medicare office paragraph for where to find your nearest one).

How Medicare Pays You

How you’ll receive your Medicare benefits depends on whether your account is paid. If it is, you can choose to be paid by electronic funds transfer (see the section entitled ‘Registering Bank Details to Make Claims’ for more details on this), cash (if you claimed at your local Medicare office) or cheque. If your account isn’t fully paid, you’ll be sent a cheque which will be made payable to your doctor.

Registering Bank Details to Make Claims

You can register your bank account details by:

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