What you need to know
The Medicare Benefits Schedule (MBS) is a list of medical services the Australian government will pay a rebate towards when you need medical treatment.
Each service has a schedule fee – this is the amount that the Australian government deems as a fair fee.
Doctors and specialists do not need to adhere to the Medicare schedule fee if you are treated in a private hospital – this is where out of pocket expenses can occur.
The Medicare Benefits Schedule (MBS) is a list of medical services which are covered (subsidised) by the Australian government.
Each medical service is given a schedule fee (sometimes referred to as the MBS fee) by the Australian government based on what it thinks is a fair fee. The Medicare schedule fee rebates are as follows:
- 100% for consultations with a GP
- 85% for non-GP services from Medicare when the services are provided out of hospital
- 75% for in-hospital services you receive as a private patient (private health insurance covers the remaining 25%)
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
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
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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.
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