What the Medicare Benefits Schedule is and why it matters

The Medicare Benefits Schedule (MBS) is the official list of medical services and procedures that Medicare will pay for, along with how much the government pays for each one. It is not a list of what you are covered for — it is the reference document that doctors, dentists, allied health professionals, and hospitals use to work out what Medicare will reimburse them when they treat you.

When your doctor performs a service or orders a test, they look up the item number on the MBS to find out what Medicare will pay. If the service is on the schedule, Medicare covers part or all of the cost (depending on the service and your circumstances). If it is not on the schedule, Medicare does not pay, and you pay the full amount out of pocket.

The MBS is maintained by the Department of Health and is updated regularly — sometimes monthly — as new services are added, removed, or have their payment amounts changed. Understanding how it works helps you know what to expect when you receive a bill or a statement from your doctor.

Key Takeaways

  • The Medicare Benefits Schedule lists every service Medicare will pay for, assigned an item number and a payment amount that varies by service type.
  • Your doctor uses the MBS to determine what Medicare will reimburse them; if a service is not listed, you pay the full cost yourself.
  • The schedule is updated regularly, so payment amounts and covered services can change throughout the year.
  • You can search the MBS online using the official government tool, which shows the item number, description, and Medicare payment amount for each service.
  • Gap payments (the difference between what Medicare pays and what your doctor charges) are your responsibility unless you have private insurance that covers them.

How the MBS is organized and what information it contains

The Medicare Benefits Schedule is organized by category — general practice, specialist consultations, diagnostic imaging, pathology, surgery, dental, allied health, and others. Each service has a unique item number (usually four digits), a description of what the service is, and the amount Medicare will pay for it.

When you receive a bill or an explanation of benefits from Medicare, you will see item numbers on it. These numbers correspond directly to the MBS. For example, a standard GP consultation might be item 99213, and the MBS will show exactly what Medicare pays for that item and under what conditions.

The schedule also notes whether a service requires a referral, whether it is bulk-billed (the doctor accepts the Medicare payment as full payment), and whether there are any restrictions — for instance, how many times per year you can have that service covered, or whether it is only covered for certain age groups or conditions.

The difference between the MBS and your out-of-pocket costs

Medicare pays a set amount for each service on the MBS. However, your doctor can charge more than that amount. The difference between what Medicare pays and what your doctor actually charges is called the gap, and you are responsible for paying it.

For example, if the MBS says Medicare will pay $150 for a service, but your doctor charges $200, you pay the $50 gap. Some doctors bulk-bill, meaning they accept the Medicare payment as their full fee and charge you nothing extra. Other doctors charge a gap, and you need to pay it at the time of the appointment or receive a bill later.

If you have private health insurance, your insurance may cover some or all of the gap, depending on your policy. It is worth checking your insurance documents or calling your insurer to understand what gaps they cover.

How to search the Medicare Benefits Schedule yourself

You do not need to wait for your doctor to tell you what Medicare will pay. The Department of Health publishes the MBS online, and you can search it yourself using the official Medicare Benefits Schedule search tool on the Services Australia website.

To search, you can enter a service description (for example, "blood test" or "knee X-ray"), an item number if you already have one, or the name of a procedure. The search results show the item number, a full description of the service, the Medicare payment amount, and any conditions or restrictions that explore.

The search tool also shows the effective date of the information, so you know whether the payment amount is current. Because the MBS is updated regularly, it is a good idea to check the date if you are comparing costs or planning ahead for a procedure.

When the MBS changes and how it affects you

The Medicare Benefits Schedule is not static. Services are added when new treatments become available and are deemed effective. Services are removed if they are no longer recommended or if evidence shows they do not work. Payment amounts are adjusted, sometimes up and sometimes down, based on government decisions about funding.

These changes can happen monthly, though major updates are often announced in advance. If you are having a procedure done, the payment amount that applied when your doctor quoted you may have changed by the time you have the procedure. It is worth asking your doctor to confirm the current MBS item number and payment amount closer to your appointment date.

You can stay informed about MBS changes by checking the Services Australia website, which publishes a list of recent changes. Some changes are minor (a small adjustment to a payment amount), while others are significant (a new service being covered, or an old one being removed).

Understanding bulk billing and the MBS

When a doctor bulk-bills, they are agreeing to accept the MBS payment amount as their full fee. This means you pay nothing at the appointment — Medicare pays the doctor directly, and there is no gap for you to cover.

Not all doctors bulk-bill all services. Some bulk-bill GP visits but charge a gap for specialist consultations. Others bulk-bill for certain patient groups (children, pensioners, concession card holders) but charge a gap for other patients. It is always worth asking your doctor or their reception staff whether they bulk-bill before your appointment, so you know what to expect.

Bulk billing rates vary by location and by service type. In some areas, most GPs bulk-bill; in others, gaps are more common. If cost is a concern, asking about bulk-billing options when you book an appointment can help you manage your healthcare expenses.

How specialists and hospitals use the MBS

Specialists, dentists, and allied health professionals (physiotherapists, psychologists, and others) all use the MBS in the same way as GPs. They look up the item number for the service they provide and bill Medicare accordingly.

For hospital care, the MBS works differently. Public hospitals are funded through a separate system, and you do not see an MBS item number on your bill. Private hospitals do use the MBS, and your doctor will bill Medicare based on the relevant item numbers for your treatment.

If you are referred to a specialist, ask them whether they bulk-bill or charge a gap. Specialist consultations can have significant gaps, so knowing in advance helps you budget and make informed decisions about your care.

Frequently Asked Questions

Can I find out what Medicare will pay before I see my doctor?

Yes. You can search the Medicare Benefits Schedule online using the Services Australia website. If you know what service or procedure you need, you can look up the item number and see exactly what Medicare will pay. You can also call your doctor's office and ask them what item number they will use and what the current MBS payment is.

What happens if my doctor charges more than the MBS amount?

The difference is called a gap, and you are responsible for paying it. Some doctors bulk-bill and do not charge a gap. Others charge a gap, which you pay at the appointment or receive a bill for later. Private health insurance may cover part or all of the gap, depending on your policy.

Does the MBS cover dental work?

Medicare covers some dental services through the MBS, but coverage is limited. It includes services like tooth extractions and treatment of dental infections. Routine dental care like cleanings and fillings is not covered by Medicare. Dental insurance or private payment is needed for most dental work.

How often does the Medicare Benefits Schedule change?

The MBS is updated regularly throughout the year, sometimes monthly. Changes include new services being added, old ones being removed, and payment amounts being adjusted. You can check the Services Australia website for a list of recent changes, or ask your doctor to confirm the current item number and payment amount before your appointment.

Is the MBS the same in every state?

Yes. The Medicare Benefits Schedule is a national list maintained by the Department of Health. The same item numbers and payment amounts explore across all states and territories. However, the availability of bulk-billing doctors and specialists may vary by location.