Medicare & healthcare costs

If your child has inflammatory bowel disease (IBD), you may need to attend specialist appointments, have regular blood and stool tests, undergo medical procedures and access ongoing treatment.

In Australia, Medicare helps cover the cost of many essential healthcare services for eligible people, including children living with Crohn’s disease and ulcerative colitis.

However, not every healthcare service is fully covered by Medicare, and some families may have out-of-pocket expenses.

Understanding how Medicare works can help you plan for appointments, treatments and other costs associated with managing your child’s IBD.

💳 What does Medicare cover?

Medicare provides benefits for eligible medical services, including many services involved in diagnosing and managing IBD.

Depending on your child’s circumstances, Medicare may contribute towards:

• GP appointments: Eligible consultations and medical services provided by your GP.

• Specialist appointments: Consultations with paediatric gastroenterologists and other specialists when Medicare requirements are met.

• Pathology tests: Eligible blood tests, stool tests and other investigations requested by a healthcare professional.

• Medical imaging: Certain scans and other diagnostic imaging services when Medicare eligibility requirements are met.

• Hospital treatment: Eligible treatment as a public patient in a public hospital.

• Some medical procedures: Eligible procedures performed in approved settings when Medicare requirements are satisfied.

The amount covered depends on the service, the Medicare Benefits Schedule (MBS) item number and the circumstances in which the service is provided.

Some services may be fully covered, while others attract a gap payment or are not eligible for a Medicare benefit.

👩‍⚕️ Specialist appointments & Medicare rebates

Children with IBD often need regular appointments with a paediatric gastroenterologist to monitor their condition, review treatment and assess how well their medication is working.

If you see a specialist privately, Medicare generally pays a rebate towards eligible consultations when the relevant requirements are met.

The specialist sets their own fee, which may be higher than the Medicare rebate.

For example, if a specialist charges $250 and the Medicare rebate is $80, your out-of-pocket cost would be $170.

This is an illustrative example only. Actual specialist fees and Medicare rebates vary.

There are three common billing arrangements:

• Bulk billing: The provider accepts the Medicare benefit as full payment for the service, so there is no out-of-pocket cost for that service.

• Medicare rebate with a gap: You pay the provider’s fee and receive a Medicare rebate, leaving you to cover the difference.

• Public hospital outpatient appointments: Eligible patients generally receive public hospital outpatient care without a consultation fee, although waiting times and service availability vary.

Before booking a private appointment, ask the specialist’s rooms about their consultation fee, the expected Medicare rebate and the amount you will need to pay yourself.

A referral is generally required to receive a Medicare rebate for a specialist consultation.

🏥 Public vs private hospital costs

Your child may receive treatment through a public hospital or a private hospital, depending on their needs, eligibility and care arrangements.

Public hospital care

If your child is eligible for Medicare and is treated as a public patient in a public hospital, medically necessary public hospital treatment is generally provided without charge.

This can include eligible inpatient treatment, hospital accommodation, medical care and necessary procedures provided as part of their public hospital treatment.

Public hospital services may also include specialist outpatient clinics, although appointment availability and waiting times vary.

Private hospital care

If your child is treated as a private patient, costs may include:

• Hospital accommodation and facility fees.

• Specialist and anaesthetist fees.

• Procedures and investigations.

• Medicines and other hospital-related expenses.

Medicare and private health insurance may cover some eligible costs, but they do not necessarily cover everything. Waiting periods, policy exclusions, excesses and other restrictions may apply.

Before choosing private treatment, ask the hospital and treating specialists for an estimate of the likely costs and any expected out-of-pocket expenses.

💊 Medication costs & the Pharmaceutical Benefits Scheme

Children with IBD may need ongoing medication to control inflammation and maintain remission. The cost depends on the medication prescribed, whether it is listed on the Pharmaceutical Benefits Scheme (PBS), and where and how it is supplied.

The PBS subsidises many prescription medicines for eligible patients, helping reduce the amount families pay at the pharmacy.

From 1 January 2026, the maximum patient co-payment for most PBS prescriptions is $25 per prescription for general patients and $7.70 for eligible concession cardholders. Some medicines may cost more because of brand premiums or other charges.

However, not every IBD medication is available on the PBS under every circumstance.

Some medicines require specific eligibility criteria or prior approval, and certain treatments may be supplied through hospitals rather than a community pharmacy.

If your child is prescribed a new medication, ask their specialist or pharmacist:

• Is this medication covered by the PBS?

• Will we need to pay a prescription co-payment or any additional fees?

• Are there eligibility requirements or approvals we need to know about?

• Is the medication supplied through a pharmacy or the hospital?

• Are there any programs or other arrangements that may reduce the cost?

You can find more information on the Australian Government's PBS website.

💰 What are out-of-pocket expenses?

Out-of-pocket expenses are the costs your family pays yourself after any Medicare rebates, insurance payments or other subsidies have been applied.

For families managing childhood IBD, these expenses can add up over time.

Common costs may include:

• GP appointments that are not bulk billed.

• Gaps between private specialist fees and Medicare rebates.

• Private hospital fees, excesses and accommodation costs.

• Medicines that are not fully subsidised.

• Non-covered tests, procedures or allied health appointments.

• Travel, parking and accommodation when attending specialist appointments.

• Special nutritional products or supplements recommended as part of your child's care.

Keep receipts and records of your healthcare expenses so you can track spending throughout the year and identify costs that may be eligible for rebates or assistance.

🛡️ Medicare Safety Nets: Help with ongoing medical costs

If your child needs frequent specialist appointments, medical tests or other eligible services outside hospital, your family's out-of-pocket expenses may become substantial.

Medicare Safety Nets can help eligible people receive higher Medicare benefits once their eligible medical expenses reach a specified threshold within a calendar year.

There are two main Medicare Safety Nets:

• Original Medicare Safety Net: Provides higher benefits for eligible out-of-hospital services once the relevant gap threshold is reached.

• Extended Medicare Safety Net: Can provide additional benefits for eligible out-of-hospital services after the relevant out-of-pocket threshold is reached. Benefit caps may apply to some services.

For families, eligible expenses may be combined by registering as a Medicare Safety Net family with Services Australia. This can help families reach the relevant threshold sooner.

Important: Medicare Safety Nets do not cover every healthcare expense. They generally apply to eligible out-of-hospital medical services, not hospital accommodation, medicines or every allied health service.

Thresholds change over time, so check the current amounts and family registration requirements through Services Australia — Medicare Safety Nets.

🧾 Practical ways to manage healthcare costs

Managing ongoing healthcare expenses can be challenging, especially when your child needs regular appointments and treatment.

A few practical steps may help:

Ask about fees before appointments. When booking a private specialist, ask for the consultation fee, expected Medicare rebate and estimated out-of-pocket cost.

Check whether bulk billing is available. Some GPs and other providers bulk bill eligible services, meaning you do not pay a gap for those services.

Keep track of family medical expenses. Review your Medicare Safety Net position and register your family if required.

Check prescription costs. Ask your pharmacist whether your child's medication is PBS-listed and whether any additional charges apply.

Ask about travel assistance. If you need to travel a significant distance for specialist treatment, check whether your state or territory offers a patient travel assistance scheme.

Discuss financial concerns with your healthcare team. If the cost of treatment is becoming difficult to manage, tell your child's specialist or IBD nurse. They may be able to direct you to hospital social workers, patient assistance programs or other relevant support services.

💙 What if you cannot afford your child's healthcare?

If healthcare costs are placing pressure on your family, you are not alone. Ongoing medical appointments, prescriptions and travel can create financial stress for families living with childhood IBD.

Speak with your child's healthcare team before delaying appointments or stopping prescribed medication because of cost.

Depending on your circumstances, you may be able to access assistance through hospital social work services, state or territory travel schemes, concession arrangements or other support programs.

Your child's healthcare team can help you explore the options that may be available to your family.

🔗 Where can you find more information?

• Services Australia — Medicare: Information about Medicare benefits, claims and eligibility.

• Medicare Safety Nets: Learn how family medical expenses may qualify for higher Medicare benefits.

• Pharmaceutical Benefits Scheme: Check information about subsidised prescription medicines.

• Medical Costs Finder: Compare information about the costs of GP and specialist services.

• Your local public children's hospital: Ask about outpatient services, financial counselling and support available to families.

• Your state or territory health department: Find information about patient travel assistance and other local healthcare support.

Remember: Medicare can help with many healthcare expenses, but it does not cover every cost associated with managing childhood IBD. Understanding the available rebates, subsidies and assistance programs can help you plan ahead and make informed decisions about your child's care.

This article provides general information for families in Australia and is not financial or medical advice. Coverage, eligibility, fees and rebates vary according to individual circumstances. Check current requirements with Services Australia, your healthcare provider or the relevant government department.