How much does Medicare cover for out hospital services?

Certain out-of-hospital medical services are paid by Medicare and are therefore not covered by private health insurance. These include visits to or by your doctor plus medical services (including pathology and radiology) when provided to you as an outpatient or in a hospital emergency department (as the patient is not admitted). A hospital visit by a paediatrician to a newborn also falls into this category if the baby has not been admitted to the hospital as a patient in their own right.

In all these cases, claims should be lodged with Medicare for payment.

Medicare pays 85% of its Scheduled Fee for medical services provided to people who have not been admitted to hospital.


How much does Medicare pay for in medical services?
Medicare pays 75% of the Scheduled Fee for medical services provided to people who have been admitted (in-patient).

Who pays the difference?
For medical services provided to you as a hospital in-patient, Emergency Services Health pays the gap between the Medicare benefit and the Scheduled Fee.

In the vast majority of cases where medical services are billed under our Access Gap Cover scheme, we can also cover the difference between the Scheduled Fee and actual fee charged. Where the fee exceeds that covered by Access Gap Cover, the service provider should advise you of any gaps that exist and what you will need to pay.

What about out-of-pocket costs?
We strive to minimise treatment costs to members. While we have succeeded in covering most situations, there are some occasions when members will incur a charge from the service provider:

  • Charges greater than the Scheduled Fee that do not fall within the Access Gap Cover.
  • Charges greater than those recognised for Access Gap Cover.
  • Non in-patient medical services, including those medical services provided while treated in the emergency department of a hospital.
  • Visits by a paediatrician to a newborn who has not been admitted to hospital as a patient in their own right.

For more information on what Medicare covers visit this website.


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