1. The “100% of MBS” Rule
The Australian Government sets a “Schedule Fee” for every medical service (e.g., a standard 15-minute GP visit is approximately $42.85 in 2026).
- What OSHC Covers: 100% of that $42.85.
- What Doctors Charge: In 2026, many private doctors charge $80.00 to $110.00 for a standard visit.
- The Result: Your insurance pays $42.85, and you must pay the remaining $37.15 – $67.15 out of your own pocket. This is called the “Gap Fee.”
2. How to Get 100% Coverage (No Out-of-Pocket)
To ensure your appointment is completely free, you must visit a Direct Billing clinic.
- Direct Billing: The doctor agrees to accept only the MBS fee ($42.85) as full payment. They bill your insurer directly, and you walk out without paying a cent.
- Where to find them: Use your provider’s app (Allianz MyHealth, MyBupa, or Medibank OSHC) and filter for “Direct Billing” or “Network Providers.”
3. 2026 Coverage Summary Table
| Service Type | OSHC Benefit (2026) | Potential Out-of-Pocket |
| GP Visit (Standard) | 100% of MBS Fee | $0 at Direct Billing clinics; $40+ elsewhere |
| Specialist Visit | 85% of MBS Fee | Usually $100+ (Specialists charge high gaps) |
| Blood Tests / X-rays | 85% of MBS Fee | Small gap fee often applies |
| Public Hospital | 100% Coverage | $0 for shared ward/emergency |
| Prescriptions | Partial (up to $50/item) | You pay the first ~$7.70 (PBS co-payment) |
4. Major 2026 Benefit: 24/7 Digital Doctors
If you can’t find a local direct-billing clinic, most 2026 OSHC plans now include unlimited $0 Telehealth:
- Bupa Blua / Allianz Doctors on Demand: You can speak to a doctor via video call 24/7 for free. They can issue medical certificates and prescriptions directly to your phone.
- Sonder (Allianz/Medibank): Provides 24/7 mental health and safety support, often with no waiting periods.
