What is the MBS? (Medicare Benefits Schedule)

What is the MBS?

The Medicare Benefits Schedule (MBS) is a list of medical services which are covered (subsidised) by the Australian government. If you're eligible for Medicare, then the MBS is the list of services that you can get for free or subsidised as a public patient.

In the schedule, each medical service is given a fee (sometimes referred to as the MBS fee). This is based on what the government thinks is a fair fee. These fees change over time.

What will you actually pay for MBS items?

So here's the thing - the MBS doesn't always apply. And when it applies is kind of arbitrary based on the doctor you're seeing. There are a few standards for how much Medicare will pay, listed below, but there are conditions for each one.

Seeing a GP: Medicare will provide 100% of the MBS fee for consultations with a GP. If the GP bulk bills, that will cover your whole bill. Not all GPs bulk bill, so check before your appointment.

Non-GP out-patients: Medicare will pay 85% of the MBS fee for non-GP services from Medicare when the services are provided out of hospital. So you'll typically pay at least that 15%, but many specialists will charge more than the MBS, so you might be paying more again.

Public Hospitals: If you're a public patient in a public hospital, you won't be charged for your treatment. There are some downsides of public hospitals, but cost ain't one of them.

Private Hospitals: Medicare will pay 75% of the MBS fee for in-hospital services you receive as a private patient. If you have private hospital cover it will cover the rest, along with the other hospital fees. However, private hospital insurance might not fully cover the cost of your surgeon and specialists, leaving you with out-of-pocket costs, which can be in the hundreds or thousands of dollars for some treatments.

Out of pocket fees

If you are treated in a private hospital and have private health insurance, the MBS fee does not guarantee you will have no out of pocket expenses. The Medicare schedule fee is only a recommendation – doctors and specialists have the freedom to set their own fees for the services they provide and may charge more than the MBS fee.

What benefits are covered under the MBS?

The MBS provides benefits for an extensive range of medical services, procedures and consultations, including:

• Consultation fees for doctors and specialists
• Tests and examinations doctors require to diagnose and treat illnesses, for example X-rays, ultrasounds and pathology tests
• Most surgical and therapeutic procedures carried out by doctors
• Eye tests performed by optometrists
• Some surgical dental procedures carried out by approved dentists
• Some specified dental items listed under the Cleft Lip and Palate Scheme
• Psychologist consultations
• Some specified items for allied health services, for example items to help manage chronic diseases, and services for patients with a terminal medical condition and complex care requirements

What doesn’t the MBS cover?

There are also plenty of medical services that are not included in the MBS, such as:

• Treatment as a private patient in a public hospital (there is no charge for care and treatment as a public patient in a public hospital)
• Hospital costs incurred as a private patient, such as hospital accommodation and operating theatre charges
• Dental examinations and treatment
• Home nursing services
• Acupuncture (unless it is provided as part of a doctor’s consultation)
• Emergency or non-emergency ambulance services
• Prescription glasses, frames or contact lenses
• Hearing aids and other medical appliances
• The cost of prostheses (except approved external breast prostheses covered as part of the External Breast Prostheses Reimbursement Program)
• Medications (these are covered under the Pharmaceutical Benefits Scheme)
• Any medical and hospital costs incurred overseas (these can be covered by international travel insurance)
• Medical costs which a third party is responsible for paying (for example, a service you receive may be covered by compensation insurance or by your employer)
• Medical services that are not clinically necessary
• Cosmetic surgery
• Medical examinations you are required to undergo when applying for life insurance or in order to access superannuation benefits
• Eye therapy

How private health insurance can help

Private health insurance can cover treatment in a private hospital and out of hospital costs such as dental, optical and physio which Medicare doesn't cover. This is called extras cover. Make sure you're aware of which services are covered by a hospital policy and which services fall under the auspices of extras cover before choosing a health fund.

What are gap cover schemes?

To help reduce and even eliminate out of pocket medical expenses, many private health funds run gap cover schemes. These schemes provide additional benefits to cover some or all of the gap between what your doctor charges and the MBS fee.

Doctors or specialists must agree to participate in a fund’s gap cover scheme in order for you to be able to claim benefits for their services. If your fund has a gap cover scheme in place, it will be able to provide you with a list of doctors or specialists that participate in the scheme.

Although gap cover arrangements vary, in most cases your doctor will be required to bill your health fund directly rather than impose any additional charge on you. The scheme will also only apply to certain medical services, so check with your health fund to find out exactly what’s covered and how to find a participating doctor.

Frequently asked questions about the MBS

• How does the MBS work?

  The MBS lists the medical services Medicare subsidises and sets a fee for each one. It's also integral to how private health insurance works. When you're treated as a private patient in hospital, Medicare pays 75% of the MBS fee for your doctors' services, and if your hospital cover includes the service, your insurer must pay at least the remaining 25%. Public patients in public hospitals aren't charged for their treatment.

• Will I have out of pocket costs for treatment in a public hospital?

  No. If you attend a public hospital as a public patient, you won't be charged for care or treatment. According to the Department of Health, "Public hospital services are to be provided free of charge to eligible persons who choose to be treated as public patients in accordance with the 2020-2025 Addendum to the National Health Reform Agreement."

• What is the MBS and PBS?

  The Pharmaceutical Benefits Scheme (PBS) is a list of all government-subsidised medicines in Australia. This is designed to ensure prescription medication is affordable. The PBS is separate from the MBS which focuses primarily on medical services.

To make sure you get accurate and helpful information, this guide has been edited by Tim Bennett as part of our fact-checking process.

Written by

Gary Ross Hunter

Journalist

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Gary Ross Hunter has over 6 years of expertise writing about insurance, including life, health, home, and car insurance. Having reviewed hundreds of product disclosure statements and published over 800 articles, he loves simplifying complex insurance topics for everyday readers. Gary has contributed to major outlets like Yahoo Finance, The Sydney Morning Herald, and news.com.au, and holds a Bachelor of Arts (Honours) in English Literature from the University of Glasgow, along with a Tier 2 General Advice certification, ensuring his work adheres to ASIC’s RG146 standards. See full bio

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