[Guides](/guides) How Medicare benefits work: schedule fees, 75%, 85% and 100% ============================================================ Updated 28 October 2026 Every Medicare item has a **schedule fee** set by the Australian Government. The **Medicare benefit** is a percentage of that fee: **100%** for non-referred GP attendances out of hospital, **85%** for other out-of-hospital services, and **75%** for services to privately admitted patients in hospital. Doctors set their own fees. The **gap** is the difference between what you charge and what Medicare pays. The three benefit levels ------------------------ BenefitWhen it appliesExample (1 July 2026 fees)100%Non-referred GP attendances for patients who are not admitted, and services by a practice nurse or Aboriginal and Torres Strait Islander health practitioner on behalf of a GP[Item 23](/items/23): fee $45.05, benefit $45.0585%Other services out of hospital, including specialist consultations, procedures, pathology and imaging[Item 104](/items/104): fee $103.95, benefit $88.4075%Professional services provided as part of an episode of hospital treatment for a private patient[Item 104](/items/104) in hospital: benefit $78.00 Public patients in a public hospital are treated free under the hospital agreement, so no MBS benefit applies to them. The greatest permissible gap ---------------------------- For expensive out-of-hospital items, the 85% benefit is lifted so the gap between the schedule fee and the benefit never exceeds a fixed dollar amount: the **greatest permissible gap (GPG)**. The benefit is the schedule fee less the GPG whenever that is more than 85% of the fee. - From 1 November 2025, the GPG is **$104.50**. - From **1 November 2026**, it is **$108.50**. It is indexed every 1 November in line with the June-quarter CPI. In practice this only matters for out-of-hospital items with a schedule fee above about $720. The 85% benefits shown on [MBS Search](/) already include the GPG adjustment. Working out the patient’s gap ----------------------------- **Out of hospital:** gap = your fee − Medicare benefit. > A GP charges $80 for [item 23](/items/23). Medicare pays $45.05 (100%), so the patient pays **$34.95**. > > A specialist charges $180 for [item 104](/items/104). Medicare pays $88.40 (85%), so the patient pays **$91.60**. Medicare never pays more than the fee charged. If you charge less than the benefit, the benefit is reduced to your fee. **In hospital:** Medicare pays 75% of the schedule fee, and a health fund covering the service must pay at least the remaining 25%. The patient’s gap is what you charge above the schedule fee, unless you bill under the fund’s no-gap or known-gap arrangement. See [in-hospital billing and gap cover](/guides/in-hospital-billing-and-gap-cover). Bulk billing ------------ When you bulk bill, you accept the Medicare benefit as full payment and the patient assigns their benefit to you. You can’t add other charges for that service, such as a booking fee, record-keeping fee or annual administration fee. The one exception is the cost of a vaccine supplied from your own stock. Bulk billing incentive items (for example [10990](/items/10990)) can be claimed with eligible bulk-billed services. Since 1 November 2025 they apply to all Medicare-eligible patients, not just children and concession card holders. Practices registered in the Bulk Billing Practice Incentive Program also receive a quarterly 12.5% payment on MBS benefits for eligible services, split evenly between the GP and the practice, if they bulk bill every eligible service. When fees change ---------------- MBS fees are indexed on **1 July** each year. On 1 July 2026 the indexation factor was **2.6%** for most general medical services, most diagnostic imaging and several pathology groups. Item descriptors and rules can change in any monthly MBS update. Frequently asked questions -------------------------- ### Can I charge more than the MBS schedule fee? Yes. Doctors set their own fees for private services. The Medicare benefit stays the same, so anything above the benefit is the patient’s out-of-pocket cost. ### Why is the benefit for my item more than 85% of the fee? For out-of-hospital items with high schedule fees, the benefit is the schedule fee less the greatest permissible gap ($104.50 to 31 October 2026, then $108.50 from 1 November 2026), whenever that is higher than 85%. ### Why do GP items pay 100%? Non-referred GP attendances for patients who are not admitted attract a benefit of 100% of the schedule fee. Most other out-of-hospital services attract 85%. ### Can I charge a booking fee if I bulk bill? No. If you bulk bill a service you accept the benefit as full payment, and you can’t raise any additional charge for that service, including a booking or administration fee. The only exception is the cost of a vaccine supplied from your own stock. ### Do the patient’s out-of-pocket costs count towards a safety net? Out-of-hospital costs do. Gap amounts count towards the Original Medicare Safety Net, and out-of-pocket costs count towards the Extended Medicare Safety Net. In-hospital services don’t count. See [Medicare safety nets explained](/guides/medicare-safety-nets). Sources ------- - [MBS general explanatory note GN.10.26: Medicare benefits](https://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=GN.10.26&qt=noteID) - [Department of Health: Medicare safety nets and the GPG](https://www.health.gov.au/topics/medicare/about/safety-nets) - [MBS note GN.7.17: additional charges for bulk billed services](https://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=GN.7.17&qt=noteID) - [Bulk Billing Practice Incentive Program](https://www.health.gov.au/our-work/bulk-billing-incentives-in-general-practice/about) - [MBS news: 1 July 2026 indexation](https://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/news-260701) More guides ----------- - [Medicare safety nets explained: original and extended (EMSN) thresholds for 2026](/guides/medicare-safety-nets) - [In-hospital billing: the 75% benefit, the 25% fund benefit, and no-gap and known-gap schemes](/guides/in-hospital-billing-and-gap-cover) - [Bulk billing incentives and BBPIP explained: 2026 amounts by MM area](/guides/bulk-billing-incentives) - [The MBS multiple operation rule and surgical assistant fees](/guides/multiple-operation-rule) - [Assignment of benefit for bulk billing: the changes from 1 July 2026](/guides/assignment-of-benefit-2026) - [MBS telehealth rules: the eligible telehealth practitioner and phone items](/guides/mbs-telehealth-rules) - [GP chronic condition management plans: items 965 and 967 explained](/guides/chronic-condition-management-plans) - [Medicare billing compliance: claim time limits, records and the 80/20 rule](/guides/medicare-billing-compliance) General information for health professionals, not legal or financial advice. Check MBS Online and Services Australia for the rules that apply to your circumstances.