Medicare Gap Fee & Rebate Calculator — Australia

Bulk-billing means the practitioner accepts the Medicare rebate as full payment for the consultation — the patient pays nothing out-of-pocket and signs an assignment-of-benefit (DB4 / DB1A). The practitioner bills Medicare directly and receives the rebate amount, which is always less than the typical market fee. For GPs seeing concession patients (pensioner, DVA, under-16), additional bulk-billing incentive items (10990, 10991, 75870, 75871) increase the effective rebate. Bulk-billing is a clinical and business decision — there is no obligation to bulk-bill.

Three benchmarks usually shape the decision: (1) the MBS scheduled fee and rebate — your floor if you bulk-bill; (2) AMA recommended fees, which are typically 2–2.5× MBS scheduled — what well-resourced private practice charges; (3) the local market median for your suburb and modality, available through professional-body member surveys (RACGP, APA, AHPRA-aligned associations). Setting your fee = rebate + a deliberate gap (say $30–$50 for a GP, $60+ for allied health) keeps the patient out-of-pocket digestible while protecting your hourly economics.

Medicare and private health insurance do not overlap for the same service in the same setting. If a service is claimable on Medicare (out-of-hospital MBS items), the patient cannot claim it on extras; if it is claimable on private extras (e.g. non-CDM physio), there is no Medicare rebate. 'No-gap' private health agreements typically apply to in-hospital specialist services where the fund and practitioner have agreed a fee that combines Medicare 75% and the fund's 25% with no out-of-pocket to the patient. Allied health on extras is reimbursed by the fund up to the patient's annual cap, not Medicare.

Medicare Easyclaim processes Medicare bulk-bill claims (DB4) and patient claims (DB1) at the point of care through an EFTPOS terminal — the rebate is paid into the patient's nominated bank account within minutes. HICAPS processes private-health-fund extras claims at the point of care for allied health — the patient pays only the gap (if any) after the fund's contribution is deducted. Most modern practice-management terminals (Tyro Health, Medipass, integrated EFTPOS) handle both rails. They are operationally similar but cover different payers.

The authoritative source is the Department of Health & Aged Care's MBS Online (mbsonline.gov.au) — search by item number, modality, or keyword. The MBS is reviewed and updated routinely with major indexation typically applied on 1 November each year. Always verify the current scheduled fee, 85% benefit, and any restrictions (referral, location, frequency) before billing. The presets in this calculator are indicative and should not be used in lieu of MBS Online for actual claims.

Most clinical health services delivered by a recognised health professional to an individual patient are GST-free under Subdivision 38-B of the GST Act — this covers GP consults, allied-health items in the Medicare list, and most psychology/physio/OT/speech sessions. GST applies, however, to: medico-legal reports, expert-witness work, employer / insurer reports, cosmetic procedures not Medicare-funded, and any business-to-business services (e.g. contracted hours to a hospital or NGO where the recipient is a business). If your annual GST turnover from those taxable supplies hits $75,000, you must register and charge GST on those line items.