Medicare Benefits Schedule (MBS) rebate for minimally invasive glaucoma surgery (MIGS) devices.

Page last updated: 06 November 2017

The MBS item previously used by doctors for the insertion of stents was originally listed with the intent for treating primary congenital glaucoma of the eye. This did not include the insertion of stents, or MIGS devices. The Australian Government has therefore restricted the use of this item on the advice of the Medical Services Advisory Committee (MSAC). This advice has determined that MIGS devices represent a new service, and as such should be assessed on all available and relevant evidence by MSAC for safety, effectiveness and cost-effectiveness before receiving public funding. Further information about the MSAC is available on its website.

The Government has agreed however that Medicare may provide benefits for the MIGS procedures through an interim Medicare item (42705) for the insertion of particular eye stents through MIGS. This interim item took effect from 1 May 2017 and is intended to remain in place until the MSAC concludes its advice regarding suitability of long term public funding for this technology. Patients should discuss the appropriateness of surgery under this interim item number with their treating doctor.

While the Government is responsible for setting MBS fees and associated rebates, it cannot compel doctors to observe the MBS fee for a particular service. Medical practitioners are free to set their own value on their services, which may exceed the Medicare rebate and the actual fee is a matter between the patient and their doctor. Practitioners are encouraged to consider the personal circumstances of their patients when determining the fees they charge, and many do so. If a patient is not satisfied with the proposed fee, they can exercise their consumer rights and seek a second opinion if they feel they can secure a better price for a medical service.

When a patient is admitted to a hospital or licensed day surgery centre as a private patient, Medicare covers 75 per cent of the MBS fee and private health insurers cover the remaining 25 per cent. In circumstances where doctors charge above the MBS fee, patients are responsible for any additional amounts, either directly or through private health insurance. Insurers can pay more than the 25 per cent of the MBS fee to reduce, or eliminate, any gap if the doctor has a ‘gap cover arrangement’ with the insurer.

Some doctors choose not to be involved in gap cover arrangements; in this case patients will usually have a gap to pay. Doctors are free to decide on a case-by-case basis whether they wish to use an insurer’s gap cover arrangement.