If you’ve ever received a Medicare rebate after a doctor’s visit or medical procedure, you’ve interacted with MBS codes—even if you didn’t realize it. These codes play a crucial role in determining how much Medicare will reimburse you and what you may have to pay out of pocket.
For many Australians, understanding how MBS codes work can be confusing. However, knowing how they affect Medicare rebates and your healthcare costs can help you plan for medical expenses and make informed financial decisions.
What Are MBS Codes?
The Medicare Benefits Schedule (MBS) is an official list of medical services subsidized by the Australian government. Every medical service that qualifies for a Medicare rebate is assigned a unique MBS code along with a schedule fee—which is the amount that Medicare considers reasonable for the service.
However, healthcare providers aren’t required to charge the MBS fee. Some may charge more, leading to gap payments (out-of-pocket costs for the patient).
Example of MBS Codes in Action
Imagine you see a specialist for a consultation. The visit is assigned MBS code 104, with an MBS fee of $100. Here’s how it works:
- Medicare covers 85% of the MBS fee for specialist consultations.
- That means Medicare will reimburse you $85.
- If your specialist charges exactly $100, your out-of-pocket cost will be $15.
- However, if the specialist charges $180, your out-of-pocket cost jumps to $95.
This gap payment is the difference between the MBS rebate and the actual fee charged.
How Medicare Rebates Work
Medicare rebates cover a percentage of the MBS fee, depending on the type of service:
| Type of Service | Medicare Rebate (%) | Who Pays the Remaining Amount? |
| GP Consultations | 100% of MBS fee | No cost if bulk billed |
| Specialist Consultations | 85% of MBS fee | Patient pays the rest |
| In-Hospital Procedures | 75% of MBS fee | Patient or private insurer |
While Medicare rebates help lower costs, patients may still need to pay a gap fee if a provider charges above the MBS schedule fee.
How MBS Codes Impact Out-of-Pocket Costs
Bulk Billing vs. Private Billing
- Bulk Billing: If a provider bulk bills, they accept the Medicare rebate as full payment, meaning you pay nothing out of pocket.
- Private Billing (Non-Bulk Billing): If a provider charges above the MBS fee, you’ll need to pay the difference between what Medicare covers and what the provider charges.
Some providers charge more because MBS fees often don’t reflect rising healthcare costs, forcing medical professionals to set higher fees to cover expenses.
Medicare Rebates for Procedures and Tests
Different procedures and diagnostic tests have specific MBS codes that determine their Medicare rebate. This applies to services like:
- Pathology tests (e.g., blood tests, biopsies)
- Radiology (e.g., X-rays, MRIs, ultrasounds)
- Surgical procedures
- Mental health services
For example, an MRI scan may have an MBS rebate, but if your radiology clinic charges more than the MBS fee, you’ll have to cover the gap.
Out-of-Pocket Costs for Surgery
If you’re undergoing surgery, the total cost depends on:
- The MBS rebate for the procedure.
- Whether your surgeon charges above the MBS fee.
- Whether private health insurance covers any remaining costs.
For hospital treatments, Medicare covers 75% of the MBS fee, but if your surgeon, anesthetist, or hospital charges above the fee, you’ll pay the gap.
How to Reduce Out-of-Pocket Costs
Use Bulk-Billing Providers
The best way to avoid out-of-pocket costs is to visit a bulk-billing GP or specialist. You can ask:
- “Do you bulk bill?” before booking an appointment.
- “What is the MBS code for this service?” so you can check rebates in advance.
Private Health Insurance
Private health insurance may cover some or all gap fees for hospital procedures. However, it doesn’t cover out-of-hospital specialist consultations unless they are part of an inpatient treatment.
Medicare Safety Net
If you have high medical expenses, the Medicare Safety Net can help. It provides higher rebates once your out-of-pocket costs reach a certain threshold in a calendar year.
This means if you regularly see specialists, your Medicare rebates will increase after you hit the threshold, reducing further costs.
How to Check Your MBS Code and Rebate
You can find out the MBS code and rebate for your medical service by:
- Asking your doctor for the MBS item number before treatment.
- Checking MBS Online.
- Using the Medicare Express Plus app to check rebates and submit claims.
Final Thoughts
Understanding MBS codes and how they affect Medicare rebates and out-of-pocket costs can help you:
- Plan for medical expenses.
- Choose bulk-billing providers when possible.
- Take advantage of Medicare’s rebates and safety nets.
If you’re unsure about your expected costs, always ask your doctor for the MBS code and check the rebate amount before treatment.
