How does Medicare fit into Private Health Insurance?

How does Medicare Fit in/Work with my Private health insurance?

Medicare is Australia’s publicly funded universal health care system, operated by the government authority Medicare Australia. Residents with a Medicare card can receive subsided treatment from medical practitioners (such as GP’s and specialists) who have been issued a Medicare provider number, and fully subsidised treatment in Public hospitals.

Medicare is also extremely important when it comes to private health and the way it works, especially when it comes to hospital admissions and surgeries as a private patient.  


How does Medicare work if I’m a Private Patient?

If you’re heading into hospital as a private patient to have surgery, Medicare provide part of the rebate you get for any surgeries you have performed. Typically, Medicare pay 75% of the scheduled fee for the MBS item number that identifies which procedure you’re having done, and your private health insurer pay a further 25% to make up the full 100% of the benefit.  

It's important to note that if Medicare don't cover their portion of their scheduled fee, (or any other health insurer) are unable to pay any benefits, or provide coverage for the surgery until Medicare have processed their part of the scheduled fee.

It’s also important to note that if Medicare refuse to cover a surgery or procedure, cannot cover any part of the scheduled fee, or the accommodation and theatre costs that are incurred whilst staying in a private facility. Simply put, Medicare MUST provide coverage in order for you to be covered in a private hospital with your private health insurer.


What about outside of hospital?

Medicare provide a benefits for a range of different services, such as:

  • Doctors / Specialists consultations
  • X-rays, pathology tests, other medical tests
  • Some surgical procedures (in a doctor’s rooms)
  • Some surgical procedures performed by approved dentists
  • Eye Tests
  • Emergency Room Attendance

Outside of private hospital, any service (such as the examples above) that Medicare provides a benefit for are unable to attract a benefit from private health insurance. These are known as outpatient services.  

This also works the same way for services that attract a benefit through private health insurance. Whilst Medicare typically do not pay a benefit towards a number of extras covered by private health (dental, physio etc), there are a few services that are able to get a benefit from either Medicare or private health, depending on the circumstance.  

For example: If private health cover is used to provide a benefit towards a psychologist consultation, a Medicare benefit cannot be received for the same service, and vice versa. If Medicare is used instead of private health, this means the consultation becomes an outpatient service that is unable to be subsidised by private health insurance.


Have you heard the word?

On 1 July 2021, will join forces with Frank Health Insurance.

Learn more about upcoming important dates that will affect claiming here.