About this resource
Publication date:
Publication type:
Infographic
Language:
English
MBS = Medicare Benefits Schedule
PBS = Pharmaceutical Benefits Scheme
CDBS = Child Dental Benefits Schedule
Medicare system and purpose
- Universal, publicly funded patient benefits system
- Subsidises eligible health services
- Delivered through connected programs (MBS, PBS, CDBS)
Sets system scope and intent
Funded services (MBS)
- Lists services eligible for Medicare benefits
- Each service has an item number, descriptor, schedule fee and benefit rate
- Items are grouped into categories (e.g. attendances, procedures, imaging, pathology)
Specifies eligible services
Rules and requirements
- Clinical relevance of the service
- Item-specific requirements
- Patient eligibility for Medicare
- Practitioner eligibility and participation requirements
- Services excluded or funded under other arrangements
Determines if a benefit is payable
Health service delivered
- Service provided to the patient
- Matches the relevant MBS item
- All requirements are met (including time, attendance and referral rules where applicable)
Enables claiming
Medicare claiming
- Claims can be made by patients or providers
- Bulk billing is where the provider accepts the assignment of the patient’s benefit as full payment for the service
- Claims are submitted through approved claiming channels
Triggers payment
Medicare payment
- Benefits are outlined in the MBS
- Different rates apply depending on service type and setting
- Safety Nets provide higher benefits after out-of-pocket thresholds are reached
Payment made
Integrity and compliance
- Record-keeping requirements support correct claiming
- Incorrect payments may be reviewed and recovered
- Compliance programs promote appropriate use of Medicare
- Protects public funding and system integrity
Protects system sustainability and trust
Compliance data and activities inform updates and changes to the Medicare system
Guidance, information and support
- MBS Online – MBS items, descriptors and explanatory notes
- AskMBS – written advice on the correct use of MBS items
- Services Australia – claiming, payments and provider numbers
- More about Medicare – policies, legislation and standards
- Medicare resources – factcsheets, guidelines and other resources
- Medicare contacts – list of relevant contacts and support services
Have some feedback?
Contact the Provider Support and Engagement team at Provider.Support@health.gov.au
Document reference: BID26.PSES.Framework.10.28