Your guide to what is covered by the Medicare Benefits Schedule (MBS)
The Medicare Benefits Schedule (MBS) outlines the benefit amounts you are eligible to receive from Medicare for a wide range of health services. This schedule of fees is maintained by the Australian Government and defines a fair charge for all Medicare-covered services.
What is the MBS?
Medicare forms the basis of Australia’s universal healthcare system. It allows Australians to access an extensive range of health services at little or no cost, providing benefits for everything from GP visits to complicated surgical procedures. These benefits are known as Medicare rebates, and the maximum rebate amount payable varies depending on the medical service you receive.
The MBS is a schedule of fees for medical services set by the Australian Government. It lists a range of medical consultations, tests and procedures covered by Medicare, and the schedule fee for each of those services.
The schedule fee is the amount defined by the government as a fair fee for each of these services. The Medicare rebate you receive is calculated as a percentage of the Medicare Schedule Fee as follows:
- 100% for consultations with a GP
- 85% for all other out-of-hospital services provided by a medical practitioner
- 75% for in-hospital services you receive as a private patient
However, it’s worth pointing out that the Medicare Schedule Fee does not reflect the amount a medical practitioner must charge for providing a service. Doctors and specialists have the freedom to set their own fees for the services they provide and may charge more than the Schedule Fee. As a result, you may have to pay “the gap” to cover the cost of medical treatment.
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, including:
- 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
Some of the services listed above, including private hospital costs, dental, ambulance costs and optical services, are covered by health insurance from private health funds. Private hospital accommodation and theatre fees, for example, are included in hospital cover while dental and optical services are included in 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?
Doctors and specialists are under no obligation to charge the same amount as the fee listed in the MBS for the services they provide. In many cases, medical professionals charge more than the MBS fee, so you will need to cover “the gap” between the schedule fee and the amount your doctor charges.
For example, Tony is sick and decides to visit his GP for an examination. The MBS fee for this service is $37.05, for which Tony is entitled to receive a 100% Medicare rebate under the MBS. However, the doctor charges $65 for the consultation, so Tony has to cover the remaining $27.95 out of his own pocket.
To help reduce and even eliminate your out-of-pocket medical expenses, many private health funds run what are known as 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 – this means that your choice of doctor may be restricted to those providers registered with the health fund, though in some cases doctors may have the flexibility to participate in a fund’s gap program on a case-by-case basis.
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.