EMSN caps on selected procedural items and one ultrasound item from 1 November 2012

This fact sheet provides information on the EMSN benefit caps from 1 November 2012 announced in the 2012-13 Budget for selected procedural items and one ultrasound item.

Page last updated: 25 October 2012

Extended Medicare Safety Net and EMSN capping Selected procedural items (from T8 in the MBS) and one ultrasound item

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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.

Furthermore:
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
45584 Liposuction 80% 505.40
45585 Liposuction 80% 505.40
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