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.

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:

• Dental care, including preventative dental care, crowns, bridges and dentures

• Orthodontics

• Chiropractic care

• Physiotherapy

• Optical care

• Osteopathy

• Podiatry

• Orthotics

• Speech therapy

• Eye therapy

• Occupational therapy

• Acupuncture

• Medical massage

• Naturopathy

• Psychological treatment

• Dietetics

• Hearing aids

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. 

Compare health insurance with our experts below*.

Sources

^Based on 136,746 customers between 1 Jan 2018 - 23 December 2022.

Chris Stanley is the sales & operations manager of health insurance at Compare Club. With extensive experience and expertise, Chris is a trusted leader known for his deep understanding of health insurance markets, policies, and coverage options. As the sales & operations manager of health insurance, Chris leads a team of dedicated professionals committed to helping individuals and families make informed decisions about their health insurance needs.

Meet our health insurance expert, Chris Stanley

Chris's top health insurance tips

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  Australia’s public health system is world-class, but wait times for public hospitals can be long, inconvenient - and leave you living in constant pain while you wait.

• 2

  An appropriate private health insurance policy can speed up your surgery, relieving your pain sooner.

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  Family health cover means your children are covered under the same policy as you.

• 4

  Many health insurance policies come with a 12-month waiting period for pregnancy-related cover, so it’s a good idea to get a family policy organized well before starting your family. This means your child will be covered from birth until at least their early twenties (depending on which health fund you select).