A guide to the medicare benefits schedule (mbs) health
If you’re an Aussie citizen or resident, you’ll know that Medicare covers the medical treatment from doctors and specialists in and out of hospital.
But why are some health services free, while you have to pay for others? And why are you sometimes charged a fee for treatment even if you have private health insurance?
This is where the Medicare Benefits Schedule (MBS) matters – and why it’s important to choose the right health cover for your needs.
The Medicare Benefits Schedule (MBS) sets the amount Medicare will cover for a wide range of medical services
Doctors and healthcare providers can charge higher fees than the amount listed in the MBS, leaving you with out-of-pocket costs
Choosing the right health cover for your needs can reduce or eliminate out-of-pocket in-hospital medical expenses
What is the Medicare Benefits Schedule (MBS)?
The Medicare Benefits Schedule, or MBS, is a list of fees (called ‘schedule fees’) for medical services covered by the Australian government. It also sets the amount Medicare will cover for each of those medical services.
Generally speaking, Medicare covers:
100% of the schedule fee for GP services
85% of the schedule fee for non-GP out-of-hospital services, or, if the provider bulk bills, 85% of the schedule fee with no out-of-pocket cost for the patient.
Free treatment as a public patient in a public hospital
75% of the schedule fee for medical treatment as a patient in a private hospital
For example, the schedule fee for a GP visit of less than 20 minutes is $39.10, according to the Medicare Benefits Schedule website.
This means the government calculates its benefit on the fee of $39.10. Because GP visits attract a benefit of 100% of the schedule fee, the Medicare benefit for a GP visit is $39.10.
If a GP charges more than the schedule fee ($39.10) the patient will need to pay the amount above the schedule fee.
What does the MBS cover?
The MBS contains schedule fees for a comprehensive range of medical services, procedures and consultations, including:
Consultations with doctors and specialists
Tests and examinations like X-rays, ultrasounds and pathology tests
Most surgical and therapeutic procedures
Eye tests performed by optometrists
Some dental procedures
Some psychologist consultations
Some therapeutic and support services for chronic diseases and terminal illnesses
How does the MBS work with private health insurance?
When you’re treated in a private hospital, Medicare will generally pay 75% of the MBS fee for the medical services provided. If you have appropriate hospital cover, your health fund will cover the remaining 25% of the schedule fee.
Private health insurance with extras cover can also cover treatments and health services not generally covered by the MBS, such as:
How do gap fees relate to the MBS?
Doctors, surgeons and other healthcare professionals can set their own fees, which are often higher than the schedule fee set out in the MBS.
The difference between the MBS schedule fee and the amount charged is known as a ‘gap fee’. Depending on the treatment you receive, gap fees can add up to hundreds or even thousands of dollars in out-of-pocket costs.
The good news is many private health funds offer gap cover schemes that cover some or all of the difference between the MBS schedule fee and what your healthcare provider charges.
If your health fund has a gap cover scheme, you’ll have access to a list of healthcare providers that participate in the scheme.
So if you’re looking to reduce or eliminate gap fees, it’s worthwhile doing some research to see which funds have participating providers near you. It’s also important to make sure your policy covers your specific needs.
Whether you’re thinking about private health cover for the first time or considering switching policies, it makes sense to compare your options. We saved Australians an average of $300^ when they switched policies with us.
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This guide is opinion only and should not be taken as medical or financial advice. Check with a financial professional before making any decisions.
^Based on 136,746 customers between 1 Jan 2018 - 23 December 2022.
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