Medicare Benefits Scheme and Pharmaceuticaul Benefits Schedule

Medicare Benefits Schedule (MBS)

The MBS is an Australian federal funding system/insurance scheme that covers all medical and some non-medical consultations and procedures. It is used to fund the vast majority of private practice psychiatry services.

MBS Online overview

MBS Online is managed by the Australian Government Department of Health and administered by Services Australia. MBS Online contains the latest MBS information and is updated as changes to the MBS occur. Psychiatrists can use MBS Online to access information on MBS item numbers.

Below are a range of key terms from the MBS Online platform which you need to know:

• Item descriptor - details of the legislative function of the item (what it can be used for)
• Explanatory notes - guiding notes to help interpretation. 
• The schedule fee - set by the government (what it thinks a consultation/procedure is worth) – increases 1 July each year ‘Medicare Indexation’. 
• Medicare rebate - what the patient is entitled to claim back as a percentage of the Schedule fee: 
  • 85% of the schedule fee when seeing psychiatrist as an outpatient.
  • 75% when seeing psychiatrist as an inpatient in hospital.
  • 100% when seeing a General Practitioner.

Billing

Private practice psychiatrists set their own fees for the services they provide. The AMA has recommended fees which psychiatrists can use. Psychiatrists should always explain the fee structure to patients to confirm ‘informed financial consent’.

Patients can access estimated costs for health services via the Medical Costs Finder 

MBS updates

College members are provided updates on changes and developments regarding the MBS via Psyche and the Presidents Update. MBS Online also provides updates here.

Resources

• Understanding Medicare: Provider Handbook | Australian Government Department of Health, Disability and Ageing
• Medicare Benefits Schedule (MBS) - for Mental Health - Resources - Health Professional Education Resources

Pharmaceutical Benefits Schedule (PBS)

The PBS provides Australians with affordable and timely access to necessary medicines. The PBS website lists all of the medicines available to be dispensed to patients at a government subsidised price.

Provider and prescriber numbers are required to claim under the MBS and PBS. To apply, psychiatrists will need to a Provider Digital Access (PRODA) account to access Health Professional Online Services (HPOS).

PBS categories

Medicines listed on the PBS fall under three categories:

• Unrestricted - medicines that can be prescribed without restrictions on the therapeutic uses.
• Restricted - medicines that can be prescribed if the prescriber is satisfied the patient’s condition matches the therapeutic uses listed in the PBS.
• Authority Required – restricted medicines that require prior approval from Services Australia or the DVA. Authority Required (Streamlined) are restricted medicines that don’t require prior approval but must have the relevant authority code noted on the prescription.

PBS prescribing 

For up-to-date PBS prescribing information and requirements, please refer to Services Australia Prescribing PBS Medicines. 

PBS updates

The College provides members with updates on changes and developments regarding the PBS via Psyche and the Presidents Update. PBS news is also available.

Resources

• PBS eLearning modules: Pharmaceutical Benefits Scheme (PBS) - for prescribers - Health Professional Education Resources

Contact

For enquiries about this information, contact policy@ranzcp.org.

Disclaimer: This information is intended to provide general guide to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances or information or material that may have become subsequently available.