Extended Medicare Safety Net

The Extended Medicare Safety Net

The Extended Medicare Safety Net (EMSN) provides an additional rebate for Australian families and singles who have out-of-pocket costs for Medicare eligible out-of-hospital services once an annual threshold in out-of-pocket costs has been met. Out-of-pocket costs is the difference between the doctors charge and the Medicare rebate for a service.

In this section:

Out-of-hospital services include GP and specialist attendances, as well as many pathology and diagnostic imaging services. Once the relevant annual threshold has been met, Medicare will pay for 80 per cent of any future out-of-pocket costs for Medicare eligible out-of-hospital services for the remainder of the calendar year, except for a small number of services where an upper limit or ‘EMSN benefit cap’ applies.

The EMSN thresholds are indexed by the Consumer Price Index (CPI) on 1 January each year.
In 2012 the annual EMSN thresholds are:

  • $598.80 for Commonwealth concession cardholders, including those with a Pensioner Concession Card, a Health Care Card or a Commonwealth Seniors Card, and people who receive Family Tax Benefits (Part A); and
  • $1,198.00 for all other families and singles.

EMSN benefits are paid in addition to the standard Medicare rebate and any benefits received through the Original Medicare Safety Net (OMSN). Qualification to receive benefits through the OMSN differs to that of the EMSN. To receive OMSN benefits patients must accumulate a set amount of ‘gap expenses’ (generally defined as the difference between the out of hospital Medicare rebate (85 per cent of the Schedule fee) and the Schedule fee) and once qualified, patients receive 100 per cent of the schedule fee for out of hospital services for the remainder of the calendar year.

Further information relating to the OMSN can be found in the Links section below.

EMSN Capping

As a result of a 2009-10 Budget measure, on 1 January 2010 an upper limit, or ‘EMSN benefit cap’ was placed on the amount of benefit payable through the EMSN for a select number of Medicare services, including:
  • Obstetrics services (including some pregnancy related ultrasounds);
  • Assisted reproductive technology (ART) services;
  • One type of varicose vein treatment (item 32500);
  • One type of cataract surgery (item 42702); and
  • Hair transplantation for the treatment of alopecia (item 45560).

For a capped item the method for determining the EMSN benefit is the same, that is 80% of the patient’s out-of-pocket cost once the patient has reached the EMSN threshold. If this amount is greater than the EMSN benefit cap, the patient receives the EMSN benefit cap amount. If the calculated benefit is less than the EMSN benefit cap, the patient receives the calculated benefit (which is equal to 80% of the out-of-pocket costs for the claim).

Further information on EMSN capping, including the full list of capped items can be found in the Links section below.

Review of EMSN Capping

The Minister for Health and Ageing, the Hon Nicola Roxon has tabled the ‘Review of Capping Arrangements Report 2011’ in both Houses of Parliament. The capping report is an independent review undertaken by the Centre for Health Economics Research and Evaluation (CHERE) who were engaged by the department to analyse:
  • the operation of capping of EMSN benefits;
  • the extent to which the introduction of the EMSN benefits caps has made the EMSN more sustainable into the future; and
  • any changes to fees charged, services provided and patients out of pocket costs for the capped items since the introduction of the EMSN benefits caps.

A copy of the report can be found in the Links section below.

Links

Review Reports