Medicare is Australia’s national healthcare system that provides essential medical coverage to citizens and permanent residents. However, there are significant gaps in Medicare coverage that many Australians may not be fully aware of. This comprehensive guide details what Medicare does not cover, helping you understand where you might face out-of-pocket expenses without additional insurance.
Medical Services Not Covered or Partially Covered by Medicare
Specialist Services
While Medicare provides some coverage for specialist consultations, it often covers only a portion of the total fee:
•A significant portion of specialist consultation fees (the “gap” between the Medicare rebate and the specialist’s actual fee)
•Substantial out-of-pocket costs for many specialist procedures
•Additional fees for follow-up appointments
•Higher gaps for specialists who do not bulk bill
•Costs for multiple specialist opinions
•Administrative fees some specialists charge
Note: The gap between Medicare rebates and specialist fees can often be hundreds or even thousands of dollars, particularly for surgeons, dermatologists, psychiatrists, and other high-demand specialists.
Hospital and Accommodation Exclusions
Private Hospital Costs
Medicare does not cover:
•Private hospital accommodation as a private patient
•Private room upgrades in public hospitals
•Television and phone services in hospitals
•Additional meal options in hospitals
Overseas Treatment
Medicare does not cover:
•Any medical costs incurred outside Australia
•Medical treatment received outside Australia
•Medical evacuation from overseas locations
•Emergency hospital admissions in foreign countries
•Doctor consultations while traveling internationally
•Medications purchased overseas
Medications and Pharmaceuticals
Non-PBS Medications
Medicare does not cover:
•Medications not listed on the Pharmaceutical Benefits Scheme (PBS)
•Even medications that are on the PBS listing but where the patient doesn’t 100% meet the treatment conditions or their condition doesn’t 100% match the PBS use criteria
•Treatments for uncommon cancers or rare anticancer drugs not approved by the TGA and PBAC for government subsidy via the PBS (these costs can be unlimited)
•Off-label use medications (medications prescribed for conditions other than those approved by regulatory authorities)
•Medications that don’t meet age-based eligibility criteria (even for conditions occurring in Australia, some medications may be classified as private due to patient age restrictions)
•Over-the-counter medications
•Most vitamins and supplements
•Alternative medicines
•Experimental drugs
•Vaccines not included in the National Immunisation Program (NIP), such as:
•Flu vaccines for Medicare holders aged 5-64 years (costing $20-30 per year)
•RSV (Respiratory Syncytial Virus) vaccines (costing $300-400 per dose)
•Travel vaccines like Yellow Fever, Japanese Encephalitis, and Rabies
•Some newer vaccines before they are added to the NIP schedule
Dental Services
Medicare provides very limited dental coverage, excluding most dental services for adults including:
•Routine check-ups and cleanings
•Fillings and root canals
•Extractions (unless deemed medically necessary)
•Crowns, bridges, and dental implants
•Dentures and orthodontic work
Note: The Child Dental Benefits Schedule does cover some basic dental services for eligible children under 18, but most orthodontic work remains excluded.
Vision and Eye Care
While Medicare covers basic eye tests, it does not cover:
•Glasses and frames
•Contact lenses
•LASIK and other laser eye surgeries
•Vision correction procedures
•Ongoing optometry services
Hearing Services
Medicare excludes coverage for:
•Hearing aids and devices
•Cochlear implants (except in specific circumstances)
•Routine hearing tests (unless ordered by a doctor for medical reasons)
•Batteries and maintenance for hearing devices
Allied Health and Therapy Services
Most allied health services are not covered by Medicare, including:
•Physiotherapy
•Osteopathy
•Chiropractic services
•Remedial massage
•Speech pathology
•Occupational therapy
•Podiatry (except for chronic conditions under specific programs)
•Acupuncture (unless provided by a registered medical practitioner)
•Naturopathy and homeopathy
•Dietetics (except under specific programs)
Cosmetic Procedures
Medicare does not cover cosmetic procedures that are not medically necessary:
•Cosmetic surgery (facelifts, breast augmentation/reduction unless medically necessary)
•Liposuction
•Rhinoplasty (unless medically necessary)
•Botox treatments (unless for medical conditions)
•Dermal fillers
•Tattoo removal
•Cosmetic dental procedures
Emergency and Transport Services
Ambulance Services
Medicare does not cover ambulance services, including:
•Emergency ambulance transport
•Non-emergency ambulance transport
•Air ambulance services
•Interstate ambulance services
Note: Queensland and Tasmania residents, as well as pension and healthcare card holders, have ambulance services provided through state ambulance schemes.
Medical Equipment and Aids
Medical Devices
Medicare generally does not cover:
•Mobility aids (wheelchairs, walkers, canes)
•CPAP machines for sleep apnea
•Home oxygen equipment
•Prosthetic limbs (except under specific programs)
•Wigs for medical hair loss
•Compression garments
•Blood glucose monitors
•Insulin pumps (except under specific programs)
Home Modifications
Medicare does not cover:
•Bathroom modifications for accessibility
•Ramps and rails for home access
•Other home modifications for medical needs
Specific Circumstances and Services
Elective and Non-Essential Services
Medicare does not cover:
•Elective surgeries as a private patient
•Non-essential medical procedures
•Medical certificates for employment or insurance
•Pre-employment medical examinations
•Life insurance medical examinations
Fertility and Reproductive Services
Medicare provides only partial coverage for:
•IVF and fertility treatments
•Egg and sperm freezing for non-medical reasons
•Surrogacy arrangements
•Some prenatal genetic testing
Additional Exclusions
Preventative Services
Medicare generally does not cover:
•Most preventative health screenings outside of specific government programs
•Comprehensive health check-ups not deemed medically necessary
•Preventative scans and imaging without medical indication
Alternative Treatments
Medicare does not cover:
•Most complementary and alternative medicine
•Meditation classes
•Yoga therapy
•Wellness programs
•Health retreats
Other Services
Medicare does not cover:
•Long-term nursing home care (covered under aged care system, not Medicare)
•Home nursing care (except under specific programs)
•X-rays and scans outside of hospital (unless you’re admitted or obtain referrals from your doctor to acknowledge it is necessary)
•Blood tests and pathology outside of hospital (unless you’re admitted or obtain referrals from your doctor to acknowledge it is necessary)
Important Considerations
1.Medical Necessity: Some treatments that are typically excluded may be covered if deemed medically necessary by a doctor and approved by Medicare.
2.Special Programs: Certain excluded services may be covered under specific government programs for eligible patients (e.g., chronic disease management plans).
3.State Variations: Coverage for some services (particularly ambulance) varies by state and territory.
4.Partial Coverage: Some services may receive partial Medicare coverage but still require significant out-of-pocket expenses.
5.Medicare Safety Net: The Medicare Safety Net can help reduce out-of-hospital costs once you reach certain thresholds, but it doesn’t eliminate all expenses for excluded services.
6.Changing Policies: Medicare coverage policies can change, and new items may be added to or removed from coverage.
How to Address Medicare Gaps
To cover services not included in Medicare, Australians often consider:
- Self-Insurance: Setting aside funds for potential medical expenses not covered by Medicare. eg: Trauma insurance (Life insured will be paid a lump sum of money when someone experience an illness), Total and Permanent disability(TPD) insurance when life insured lost the ability to work due to illness or disability, Income protection, Life insurance etc
- Private Health Insurance: Hospital cover for treatment as a private patient and extras cover for services like dental, optical, and allied health.
- Ambulance Cover: Specific ambulance cover (often included in private health insurance) for those not covered by state schemes.
- Government Programs: Investigating eligibility for additional government assistance programs for specific health needs.
Understanding these gaps in Medicare coverage can help you make informed decisions about your healthcare planning and avoid unexpected out-of-pocket expenses.
This guide was compiled based on information from multiple authoritative sources including nib.com.au, medipay.com.au, and hcf.com.au as of 2025. Coverage policies may change over time.
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Author Profile: Jeffrey Liu, JP, is the founder and principal adviser of Hippo Insurance (aka: Hippo Wealth), with a deep expertise in wealth protection. His extensive experience includes roles in the wealth management divisions of Westpac, ANZ, and a local multi-family office. As the host of “Riches Talk,” a podcast dedicated to cultivating personal and business growth, Jeffrey has established himself as a thought leader in developing life riches. His insights have been featured on SBS, The Australian, and Channel 7. Notably, he was a semi-finalist on Australia’s Got Talent in 2010. Learn more at http://www.hippoinsurance.com.au
