Extended Medicare Safety Net and EMSN capping Selected procedural items (from T8 in the MBS) and one ultrasound itemDownload a PDF version of factsheet (PDF 480 KB)
Download RTF version of fact sheet (RTF 134 KB)
Why were those Medicare items chosen?The 38 procedural items and one ultrasound item that have an EMSN benefit cap from 1 November 2012 were identified in either the 2009 review of the EMSN, the 2011 review of EMSN capping (both reviews completed by the Centre for Health Economics Research and Evaluation (CHERE)), or by the department’s own analysis of Medicare data. The reports found that some specialist doctors felt fewer competitive constraints on their fees if they knew their patients would reach the EMSN threshold and get 80 per cent of their out of pocket costs reimbursed through the EMSN. The changes have been made to support the long term sustainability of the EMSN.
Both the 2009 review of the EMSN and the 2011 review of EMSN capping conducted by CHERE can be found on the Department of Health and Ageing website.
What will patients and doctors need to do to comply with the changes?Doctors and patients are not required to do anything extra to comply with the changes. The EMSN benefit caps are stored in the Medicare Australia claiming systems and are applied by Medicare Australia at the time of processing the claim for payment.
What items have EMSN caps from 1 November 2012? (Excludes consultation items)The EMSN benefit caps for the selected procedures and diagnostic item are equal to 80 per cent of the Medicare Benefits Schedule (MBS) fee for the item. The MBS procedures and diagnostic item that are capped from 1 November 2012 are available at the end of this fact sheet.
How will I be affected?The majority of patients will not be affected. The caps will only apply in instances where the doctor’s fee results in a calculated EMSN benefit that is higher than the capped amount and where the patient has already reached the EMSN threshold.
· There is no change in how people qualify for the EMSN;
· There is no impact on in-hospital services as they are not eligible for EMSN benefits; and
· There are no changes to the operation of the OMSN.
The following scenarios illustrate how the EMSN caps work. The scenarios assume that the patient has already reached their EMSN threshold and is therefore eligible to receive EMSN benefits.
|From 1 November 2012, item 45617, an upper eyelid reduction, has an MBS Fee of $235.05, an out of hospital MBS rebate of $199.80 and an EMSN benefit cap of $188.05.|
Example A: No impact to patients due to EMSN caps
If the doctor charges $250.00 for the service, the patient’s out-of-pocket cost before EMSN benefits are paid is $50.20 (doctor’s fee minus the MBS rebate received). Assuming the patient has reached the relevant EMSN threshold, the EMSN benefit for this service is calculated to be $40.20 (80 per cent of the patient’s out-of-pocket cost).
As the calculated EMSN benefit is below the EMSN benefit cap amount of $188.05 the patient will receive the full $40.20 in EMSN benefits. As a result, the total cost incurred by the patient is $10.00 and EMSN capping has no impact on the patient.
Example B: Impact to patients due to EMSN caps
If the doctor charges $500 for the service, the patient’s out-of-pocket cost before EMSN benefits are paid is $300.20 (doctor’s fee minus the MBS rebate received). Eighty per cent of the out-of-pocket cost would be equal to $240.20. This amount is higher than the EMSN benefit cap of $188.05, therefore, assuming the patient has reached the relevant EMSN threshold, the maximum EMSN benefit that the patient will receive is $188.05. The total MBS benefit for this service is calculated to be $387.85 (MBS rebate plus the EMSN benefit cap). As a result, the total cost incurred by the patient is $112.15. The effect of the doctor’s billing at this rate means that the EMSN benefit cap has impacted on the patient’s out of pocket cost.
Note: Medicare benefits are rounded up to the nearest 5 cents.
What are the EMSN benefit caps that will apply?
Note: Amounts are correct to 5 cents due to rounding.
|Item Number||Description of service||EMSN benefit cap (percentage of MBS fee up to $500)||EMSN cap ($)|
|11700||Electrocardiography, tracing and report.||80%||25.00|
|14100||Laser photocoagulation for the treatment of vascular lesions||80%||122.00|
|20142||Initiation of management of anaesthesia for lens surgery||80%||95.05|
|30071||Diagnostic biopsy of skin or mucous membrane||80%||41.80|
|31200||Removal of tumour, cyst, ulcer or scar by surgical excision||80%||27.20|
|31205||Removal of tumour, cyst, ulcer or scar by surgical excision||80%||76.40|
|31521||Total male mastectomy||80%||346.80|
|31527||Subcutaneous male mastectomy||80%||416.20|
|31560||Excision of accessory breast tissue||80%||277.40|
|32501||Varicose vein treatment||80%||87.85|
|32504||Varicose vein treatment||80%||214.15|
|32507||Varicose vein treatment||80%||426.90|
|34106||Ligation of artery or vein||80%||233.40|
|35533||Vulvoplasty or labioplasty||80%||279.90|
|37619||Reversal of male sterilisation - vasovasostomy or vasoepididymostomy||80%||221.30|
|42590||Canthoplasty – eyelid surgery||80%||270.70|
|42738||Injection of a therapeutic substance into the eye||80%||240.60|
|42739||Injection of a therapeutic substance into the eye||80%||240.60|
|42740||Injection of a therapeutic substance into the eye||80%||240.60|
|45003||Single stage local myocutaneous flap repair to 1 defect, simple and small||80%||481.35|
|45025||Carbon dioxide laser for scaring on face or neck||80%||141.90|
|45026||Carbon dioxide laser for scaring on face or neck – more than 1 area||80%||318.85|
|45200||Single stage local flap, where indicated, to repair 1 defect, simple or small,||80%||227.50|
|45203||Single stage local flap, where indicated, to repair 1 defect, complicated or large,||80%||324.85|
|45206||Single stage local flap, where indicated, to repair 1 defect, on eyelid, nose, lip, ear, neck, hand, thumb, finger or genitals||80%||306.85|
|45545||Reconstruction of nipple, areola or both||80%||498.05|
|45587||Meloplasty for correction of facial asymmetry due to soft tissue abnormality||80%||712.70|
|45614||Whole thickness reconstruction of eyelid other than by direct suture||80%||470.10|
|45617||Upper eyelid reduction||80%||188.05|
|45620||Lower eyelid reduction||80%||260.85|
|45623||Ptosis of eyelid (unilateral), correction of||80%||578.45|
|45624||Ptosis of eyelid, correction of, where previous ptosis surgery has been performed||80%||749.95|
|45632||Rhinoplasty, correction of lateral or alar cartilages||80%||409.60|
|45635||Rhinoplasty, correction of bony vault only||80%||470.10|
|45652||Rhinophyma, carbon dioxide laser or erbium laser excision-ablation of||80%||285.10|
|45659||Correction of lop ear, bat ear or similar deformity||80%||417.00|
|55054||Ultrasonic cross-sectional echography in conjunction with a surgical procedure using interventional techniques||80%||87.30|