What Medicare Actually Covers in 2026 (and Where the Gaps Are)
Medicare is one of those systems Australians trust without quite understanding. We carry the green card for decades, tap it at reception desks and pharmacy counters, and mostly find out what it does and doesn’t cover at the exact moment it matters: when the receptionist mentions a gap fee, or the chemist rings up a script at ten times the price you expected. The system covers a great deal. But the edges are fuzzy, and the edges are where the surprise bills live. The good news is that 2026 has brought some genuine improvements, including the cheapest general PBS scripts in more than two decades. The less good news is that the gaps, particularly dental and optical, are as wide as ever. Here is what the card actually buys you this year, what it doesn’t, and the handful of checks that can save a household hundreds of dollars. The GP visit: why some people pay nothing and you pay $40 Medicare pays a set rebate for a standard GP consultation. What you pay depends entirely on how the practice bills. A bulk-billing clinic accepts the rebate as full payment, so you walk out without opening your wallet. A private-billing clinic charges its own fee, you claim the rebate back, and the difference is your gap. That gap is set by the practice, not by Medicare, which is why two clinics in the same suburb can charge wildly different amounts for the same ten minutes. Many practices bulk bill children and concession card holders but charge everyone else, and plenty have quietly moved from bulk billing to mixed billing in recent years. None of this is secret; it is just rarely volunteered. Ask how you will be billed when you book, and if the answer stings, the Healthdirect service finder makes it easy to compare clinics near you. Changing your regular GP is a bigger decision than chasing a free appointment, but for routine scripts and referrals, knowing a bulk-billing option exists nearby is useful leverage. Scripts: the PBS just got noticeably cheaper When a medicine is listed on the Pharmaceutical Benefits Scheme, the government pays most of the cost and you pay a capped co-payment. From 1 January 2026, that cap dropped to $25 for general patients, down from $31.60 the year before, and the biggest cut to the general co-payment in over twenty years. Concession card holders pay $7.70 a script, a rate that has been frozen since 2024 and is legislated to stay frozen through 2029. Then there is the PBS Safety Net, which far fewer people use than should. Once your household’s spending on PBS scripts passes $1,748.20 in a calendar year ($277.20 for concession card holders), scripts cost just $7.70 for the rest of the year, and nothing at all for concession holders. The catch is that someone has to be counting. Ask your pharmacist to keep a Safety Net record for your family; they can track the tally and tell you when you qualify. If your household juggles several regular medicines, this one habit can be worth hundreds of dollars in the back half of the year. Current rates are always listed on the PBS website. The big three gaps: teeth, eyes and everything physio Now for the part that catches almost every household. For adults, Medicare generally does not cover dental check-ups or treatment, glasses or contact lenses, or routine physiotherapy, podiatry and similar therapies. These are not small omissions; for many families they are the largest health costs of the year, and they sit almost entirely outside the system. There are two partial exceptions worth knowing. Children aged 0 to 17 in families receiving certain payments, including Family Tax Benefit Part A, may be eligible for the Child Dental Benefits Schedule, which covers up to $1,158 of basic dental work per child over two calendar years. Eligibility is assessed automatically, but plenty of eligible families simply never use it; you can check yours through Services Australia. Public dental services also exist for concession card holders, though waiting lists in most states are measured in months or years, not weeks. These gaps are the main reason people hold private health extras cover, and extras deserve a cold-eyed annual review. Before renewing, add up what you actually claimed on dental, optical and physio last year and hold it against the premium. If you claimed less than you paid, you are not insuring, you are donating. If you claimed more, keep it and check your limits. It is a ten-minute exercise that regularly changes minds in both directions. Mental health: more cover than most people realise If you are struggling, start with your GP. A Mental Health Treatment Plan unlocks Medicare rebates for up to 10 individual psychology sessions each calendar year, plus up to 10 group sessions. The rebate rarely covers the full fee, so ask two questions when booking: what is the gap per session, and does the practitioner bulk bill plan sessions for any patients? Some do, particularly for concession card holders, and your GP often knows who. Telehealth sessions attract the same rebates, which has quietly transformed access for women in regional areas and for anyone whose week does not accommodate a 3pm appointment across town. If cost is the barrier, Healthdirect’s guide to low-cost mental health services lists the free and subsidised options worth trying first. Newer treatments: where the out-of-pocket question matters most The most expensive surprises in Australian healthcare tend to involve newer prescription treatments. There is often a long delay between a medicine being approved by the TGA and it being subsidised on the PBS, and some medicines never make the list at all. In that window, you pay the private price, which can run to hundreds of dollars a month, with none of it counting toward the PBS Safety Net. Weight loss medication is the clearest current example. It is among the most asked-about prescriptions in the country, and the coverage rules confuse almost everyone, because
