How does Medicare work in Australia?

Medicare is Australia's public health insurance system. It covers free or subsidised treatment by doctors, specialists, and optometrists. It covers free treatment in public hospitals. It subsidises the cost of prescription medicines through the PBS. You receive a Medicare card when you enrol, and you show it whenever you visit a doctor. The government pays a set rebate for each service — if the doctor charges more than the rebate, you pay the difference (called the gap).

What is bulk billing?

Bulk billing means the doctor charges Medicare directly and accepts the Medicare rebate as full payment. You pay nothing out of pocket. Not all doctors bulk bill — some charge a gap fee on top of the Medicare rebate. When booking, ask: Do you bulk bill? If the answer is no, ask what the gap fee will be so you know before the appointment.

A gap fee is the difference between what the doctor charges and what Medicare rebates. For example, if your GP charges $90 for a consultation and the Medicare rebate is $41.40, you pay a gap of $48.60 out of pocket. Medicare then reimburses you $41.40 — usually automatically to your bank account within 24 hours. Specialists often have larger gaps. The gap is not set by Medicare — each doctor sets their own fees.

Do I need a referral to see a specialist?

Yes. To receive a Medicare rebate for a specialist appointment, you need a valid referral from a GP or another specialist. Without a referral, you will not receive any Medicare rebate and must pay the full specialist fee. GP referrals to specialists are valid for 12 months. Referrals to some allied health professionals (physiotherapy, psychology under a care plan) also come through your GP.

How Medicare Works

A visual, step-by-step guide to the Australian Medicare system. Tap each step to learn more.

📋 Source: Services Australia — Medicare. Medicare Benefits Schedule (MBS). Pharmaceutical Benefits Scheme (PBS). PBS co-payment and Safety Net thresholds current as at 2025–26.
Your doctor or healthcare provider knows your history and circumstances — always follow their personalised advice over general information.

🇦🇺 Australia only

1 You need to see a doctor

You're unwell, need a check-up, or have a health concern. Your first point of contact is a GP (General Practitioner) — your family doctor. You don't need a referral to see a GP. You can book with any GP, anywhere in Australia.

What to bring: Your Medicare card (physical or digital in the myGov app). If you don't have a Medicare card yet, check if you're eligible.

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2 At the GP — are you bulk billed?

When you arrive, two things can happen:

✅ Bulk billed

The GP charges Medicare directly. You pay $0. Medicare pays the GP the schedule fee. This is the most common model for children, concession card holders, and many practices.

💳 Gap fee

The GP charges more than the Medicare rebate. You pay the gap. Medicare reimburses the rebate portion (usually within 24 hours to your bank).

Example: GP charges $90. Medicare rebate is $41.40. You pay $90 at the desk, Medicare puts $41.40 back in your bank. Your out-of-pocket cost = $48.60. If bulk billed, you pay $0.

Tip: Always ask "do you bulk bill?" when booking. If not, ask what the gap will be. More on bulk billing →

Paid upfront? Most claims are lodged for you automatically, but if not, you can claim the rebate back yourself. How to claim your Medicare rebate →

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3 Do you need tests?

If your GP orders blood tests, X-rays, or other investigations:

🧪 Pathology

Blood tests, urine tests, swabs. Usually bulk billed at most pathology labs (QML, SNP, Laverty, etc.). You pay $0.

📷 Imaging

X-rays, ultrasounds, CT, MRI. Varies. Some bulk bill, some charge a gap. Always ask the imaging practice before your appointment.

Need to fast for your blood test? → | What to expect at your scan →

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4 Do you need a specialist?

If your GP refers you to a specialist (dermatologist, cardiologist, surgeon, etc.):

You need a GP referral to get a Medicare rebate for specialist visits. Without a referral, Medicare pays nothing and you pay the full fee.

✅ Bulk billed specialist

Rare in private practice but common in public hospital outpatient clinics. You pay $0.

💳 Gap fee

Most private specialists charge above the Medicare rebate. Gaps of $50–$300+ per visit are common. Always ask about fees before booking.

GP referrals are valid for 12 months (or 3 months for indefinite referrals). How referrals work →

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5 Do you need hospital treatment?

🏥 Public hospital

Free. As a public patient in a public hospital, Medicare covers everything — surgery, accommodation, medication, follow-up. You don't choose your doctor and may wait longer for non-urgent procedures.

🏨 Private hospital

Requires private health insurance. You choose your doctor and get a private room. Insurance covers most costs but there may be gaps (surgeon fees, anaesthetist, prostheses). Check with your insurer before admission.

Emergency: All emergency treatment in public hospitals is free for Medicare card holders, regardless of whether you have private insurance. Private vs public explained →

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6 Do you need prescriptions?

Prescription medicines are subsidised through the Pharmaceutical Benefits Scheme (PBS):

$25.00

General patient max per script

$7.70

Concession card holder per script

Many common medications cost less than the co-payment. The PBS Safety Net kicks in after you spend a certain amount per calendar year — then scripts become even cheaper or free. Safety Net calculator →

How eScripts work →

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7 Do you have a chronic condition?

If you have a condition lasting 6+ months (diabetes, asthma, arthritis, chronic pain, mental health, etc.), your GP can create a GP Management Plan. This unlocks:

✅5 subsidised allied health visits per calendar year — physiotherapy, podiatry, dietetics, exercise physiology, psychology, and more ✅Structured care coordination between your GP and other providers ✅Regular reviews to keep your treatment on track

Do I qualify for a care plan? → | I got a care plan — what next? →

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8 Need mental health support?

Your GP can create a Mental Health Treatment Plan, giving you access to:

🧠Up to 10 Medicare-subsidised psychology sessions per calendar year 💰Medicare rebate of ~$116-171 per session (general vs clinical psychologist) (you may still pay a gap depending on the psychologist's fees) 📅Sessions reset 1 January each year

You don't need to be in crisis. Book a long appointment with your GP and ask about a Mental Health Treatment Plan. Full guide →

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9 What about everything else?

Medicare does NOT cover:

❌Dental — except children (CDBS) and some public dental for concession card holders. Dental costs guide → ❌Optical / glasses — eye tests covered, glasses are not ❌Ambulance — free in QLD and TAS only. Other states require ambulance cover or private insurance. ❌Cosmetic surgery ❌Private hospital room — requires private health insurance ❌Most physiotherapy / allied health — unless under a care plan (5 visits) or DVA

DVA card holders: If you hold a DVA Gold Card, most of the above IS covered. DVA card guide →

Medicare in a nutshell

Medicare is Australia's universal public health insurance system. If you are an Australian citizen, permanent resident, or from a country with a Reciprocal Health Care Agreement, you are entitled to a Medicare card.

Medicare covers three main things: subsidised doctor visits (GP and specialist), free treatment as a public patient in public hospitals, and subsidised prescription medicines through the PBS. It does not cover dental (for most adults), optical, ambulance (in most states), or private hospital treatment.

When you visit a GP, the doctor can choose to bulk bill (charge Medicare directly, you pay nothing) or charge a fee above the Medicare rebate (you pay the gap). The Medicare rebate is a fixed amount set by the government for each type of service. If you see a specialist, you need a referral from a GP to receive the Medicare rebate.

For people with chronic conditions, Medicare funds GP Management Plans which give access to 5 subsidised allied health visits per year. For mental health, a Mental Health Treatment Plan gives access to up to 10 psychology sessions per year. Both reset on 1 January.

The Medicare Safety Net protects you if your out-of-pocket medical costs are high. Once you pass a spending threshold in a calendar year, Medicare covers a higher percentage of the cost for the rest of the year.

Apply at a Services Australia centre (Centrelink/Medicare office) or online at myGov. You need proof of identity and either Australian citizenship, permanent residency, or a visa from an RHCA country. Processing takes about 3 weeks for the physical card — you can get your number immediately.

Your Medicare card can also be accessed digitally through the myGov app. How to access My Medicare →

The Safety Net protects families and individuals who have high out-of-pocket medical costs. There are two thresholds:

Original Medicare Safety Net: After $594.40 in gap costs per calendar year (2026), Medicare covers 100% of the schedule fee for out-of-hospital services (you still pay any amount above the schedule fee).

Extended Medicare Safety Net: After $2,699.10 in out-of-pocket costs per calendar year ($861.20 for concession/FTB-A holders), Medicare covers 80% of your future out-of-pocket costs for the rest of the year.

Check your Safety Net threshold →

Medicare covers the essentials — you can live without private insurance. However, private health insurance gives you: choice of doctor in hospital, shorter waiting times for elective surgery, private hospital room, and extras cover (dental, optical, physio).

If you earn over $105,000 (single) or $210,000 (family) in 2026–27 (from 1 July 2026), you pay a Medicare Levy Surcharge of 1–1.5% if you don't have private hospital cover. This is a tax incentive to take out private insurance. The previous 2025–26 thresholds were $101,000 (single) and $202,000 (family). Source: privatehealth.gov.au.

The Lifetime Health Cover loading adds 2% to your hospital premiums for every year you are aged over 31 without hospital cover. The earlier you take it out, the cheaper it stays.