Medicare and billing

Medicare is Australia’s universal healthcare system.

For people who are eligible for Medicare, part or all of their medical costs may be subsidised, including GP visits, specialist services, some scans and tests, and PBS-listed medications. What is billed to Medicare may depend on your doctor or health professional, and the procedures and medications covered by Medicare.

You are eligible for a Medicare card if you live in Australia and you are:

• an Australian citizen

• a New Zealand citizen

• an Australian permanent resident

• applying for permanent residency

• covered by a ministerial order.

If you have not already enrolled for Medicare, you can find out how to do so here.

If you want to learn how to change your name or gender marker with Medicare, click here.

Medicare functions by using billing codes, so that claims can be easily traced and rebates provided. When the federal Sex Discrimination Amendment (Sexual Orientation, Gender Identity and Intersex Status) Act was enacted in 2013, Medicare was required to update the language and availability of some of their billing codes to allow people of all genders to access to them.

An example of this is the item number 2497. The former description which included the term ‘woman’, has been amended to read: “These items apply only to a person between the ages of 20 and 69 years inclusive who has a cervix, has had intercourse and has not had a cervical smear in the last four years.”

This change has greatly improved access for trans and gender diverse people as well as reducing potential for harm. Not all item numbers have been updated to reflect the change though and Services Australia are aware of this. They can make notes on your personal record if a claim is ever rejected.

Bulk billing is when a Medicare registered health professional chooses to be paid the Medicare billing for your appointment only, meaning there are no out of pocket costs for you. Some doctors bulk bill particular patients or populations (eg. People with a pension card, or trans people), and others don’t bulk bill at all.

A doctor or service can choose whether to bulk bill, and you can contact them beforehand to check if it’s something they do and that you can expect.

You may be able to claim a Medicare rebate for some gender affirming surgeries in Australia. How much and for what though may vary from surgeon to surgeon. When talking to your surgeon or referring doctor about fees and costs, ask about Medicare rebates and what is possible.

If you have private health insurance, it is a good idea to ask your surgeon for the Medicare item number/s they use, if applicable. You can contact your insurer to check if they cover that particular item number and, if so, the level of cover you are required to have to be partially or fully covered.

Medicare does not currently subsidise ‘cosmetic’ surgical procedures. Some affirmation surgeries in Australia are still considered cosmetic, and as a result are not subsidised by Medicare. Some private health insurance providers subsidise cosmetic procedures.

If you are a member of a private healthcare insurer, in some cases you are able to use a Two-way Medicare claim form to submit a claim to both Medicare and your insurer. You will need to fill out and submit a Two-way claim form available here, as well as a Medicare claim form (MS014) available here.

Only some medical procedures and health professionals will be applicable for claiming through both Medicare and your private health insurance, so it’s important to talk to your doctor, surgeon, or health professional about what is possible.

There are many reasons why someone may not have a Medicare card and want or require healthcare. In some cases, this will mean the patient will have to pay the full cost out of pocket, and in other cases the cost will be covered by the health professional or service.

You can get in touch with a doctor or service and ask beforehand if there are any costs involved without a Medicare card, and what these costs might be.

You can also look to ACON’s Gender Affirming Doctors List and sort by ‘No Medicare required’.