Medicare Benefits Schedule

The Government has a list of fees for services (such as surgical procedures) known as the Medicare Benefits Schedule (MBS). Medicare pays 75% of the MBS, and nib pays the remaining 25% as a benefit towards your doctors' bills, provided the procedure is not excluded on your cover. Some doctors and specialists charge more than the MBS. If this happens, you have to pay the "gap", which is the difference between the MBS and what the doctors charge.

Example

Lisa has been unwell and had to visit her doctor for an examination. The Schedule Fee for the visit is $35, and she is entitled to 100% benefit through the MBS. Lisa's doctor charges $60, leaving her out-of-pocket $25.

nib MediGap Scheme

nib's MediGap Scheme aims to reduce the gap for Patients where specialists charge above the Medicare Benefits Schedule Fee for Hospital Treatment. We will pay the 25% (non-Medicare) portion of the MBS fee and an additional amount above this, providing the doctor or specialist agrees to this amount. Doctors and specialists participating in MediGap will charge us directly at no additional cost to the Patient.

Doctors and specialists can choose on a case-by-case basis if they wish to participate in the MediGap Scheme. MediGap does not apply to consultations before or after treatment, booking or administration fees or In-Patient pathology or radiology services.

Tips for accessing nib MediGap:

  • Always ask your doctor if they'll treat you as an nib MediGap patient, and if other providers treating you (e.g. anaesthetist) will be using nib MediGap as well
  • nib MediGap will only cover services provided during your hospital stay
  • Any consultations before and after your hospital stay won't be covered
  • Administration and booking fees are not covered by nib MediGap

For more information about Medicare Benefits Schedule Fees visit the Medicare Australia website.