Extended Medicare Safety Net – 1 January 2012

This fact sheet has been updated to reflect the Extended Medicare Safety Net benefit cap amounts for 2012.

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Last Updated - 4 January 2012.

PDF version of EMSN fact sheet - Jan 2012 (PDF 79 KB)
Word version of EMSN fact sheet - Jan 2012 (Word 182 KB)

What is the Extended Medicare Safety Net?

The Extended Medicare Safety Net (EMSN) provides an additional rebate for Australian families and singles who incur out-of-pocket costs for Medicare eligible out-of-hospital services. Once the relevant annual threshold of out-of-pocket costs has been met, Medicare will pay for 80% of any future out-of-pocket costs for out-of-hospital Medicare services for the remainder of the calendar year. However, there is an upper limit on the amount of benefit that can be paid under the EMSN for a small number of Medicare services.

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

$598.80 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 singles and families.

Couples and families should contact the Department of Human Services – Medicare to register their family members as part of a Medicare eligible family. Registering as a family allows eligible out-of-pocket costs for each individual family member to count toward the family’s EMSN threshold. Couples and families need to register even if all family members are listed on the Medicare card. Registration is only required once unless family members change, for example, if a dependent child is no longer studying or you have a newborn baby.

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What are out-of-hospital services?

Out-of-hospital services include GP and specialist attendances, services provided in private clinics and private emergency departments, and many pathology and diagnostic imaging services. However, many day surgery facilitates are classified as hospitals in Australia. The distinction between in-hospital and out-of-hospital services is not always obvious. It is important that patients talk with their doctors regarding the classification and likely out-of-pocket costs for their medical treatment, including any rebates paid through Medicare.

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What services are not eligible for the EMSN?

In-hospital services are not eligible for the EMSN. Where people receive their treatment in-hospital as a private patient they are eligible for a Medicare rebate equal to 75 per cent of the Medicare Schedule fee. If they hold Private Health Insurance (PHI), they may also receive a rebate from their PHI fund.

The EMSN provides an additional Medicare rebate for eligible out-of-hospital services. It is not available for services for which a Medicare rebate is not paid and out-of-pocket costs for these services do not count towards the annual EMSN threshold.

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What is EMSN benefit capping?

The EMSN benefit cap is the maximum amount of EMSN benefits payable for a Medicare Benefits Schedule (MBS) item regardless of the fee charged by the doctor. A full list of the affected MBS items and the levels of the EMSN benefit caps appears later in this document.

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Why are some services capped?

Following an announcement in the 2009-2010 Budget, on 1 January 2010 some Medicare items were capped after they were identified as areas of concern in the Extended Medicare Safety Net Review Report 2009 (the Review report). The Review report showed that for some services, such as obstetrics and assisted reproductive technology (ART), the EMSN had been used by specialist doctors to raise their fees knowing the taxpayer would cover 80 per cent of the fee rise. This has implications for people that have not qualified for the EMSN. The EMSN benefit is intended to be a patient benefit; it is not intended to be a mechanism for doctors to increase their fees.

Since 1 January 2010 a number of MBS services have since been listed on the MBS with EMSN benefit caps in place. These services have been capped to maintain consistency with the existing capped items, or as a result of recommendations made by the Medical Services Advisory Committee (MSAC) regarding cost effectiveness.

The 2009 Extended Medicare Safety Net Review Report can be found at: www.health.gov.au/emsnreview

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How do the EMSN benefit caps work in practice?

Most people are not affected by capping. If you have a capped item you still receive the standard Medicare rebate for the service and once you have reached the EMSN threshold you are still eligible to receive EMSN benefits for all out-of-hospital services. EMSN benefit capping does not affect the way patients qualify for the EMSN, meaning that all out-of-pocket costs for all MBS services that have an EMSN benefit cap count toward the patients EMSN threshold.

All patients who have reached their EMSN threshold are eligible to receive an EMSN benefit up to the amount of the EMSN benefit cap each time that they claim for a capped service.

The EMSN benefit caps are recorded in Medicare Australia claiming systems and are applied by Medicare Australia at the time of processing the claim for payment. Practitioners are required to bill the Medicare item that best describes the service that they provide.

Additionally, under the Health Insurance Act 1973, the amount that is specified on the account must be the amount charged for the service that is specified. This means that any component for other goods or services that are not part of the MBS item that is being billed must not be included in the fee for that item. For example, the fee charged for a service cannot be loaded onto the fee for another service.

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How do I calculate my EMSN benefit?

For a capped item the method for determining the EMSN benefit is the same, that is 80 per cent 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 per cent of the out-of-pocket costs for the claim).

Out-of pocket cost is the difference between the fee charged by the doctor and the standard Medicare rebate received by the patient from Medicare before EMSN benefits are paid.

The following scenario illustrates how the EMSN caps work. The scenario assumes that the patient has already reached their EMSN threshold and is therefore eligible to receive EMSN benefits.

Item 16500, an antenatal attendance has an MBS Fee of $46.25, an out-of-hospital MBS rebate of $39.35 and an EMSN benefit cap of $32.55, for services provided after 1 January 2012. Example 1: If the doctor charges $70.00 for the service, the patient’s out-of-pocket cost before EMSN benefits are paid is $30.65 (doctor’s fee minus the MBS rebate received). The EMSN benefit for this service is calculated to be $24.55 (80% of the patient’s out-of-pocket cost). As the calculated EMSN benefit is below the EMSN benefit cap amount of $32.55, the patient will receive the full $24.55 in EMSN benefits. As a result, the total cost incurred by the patient is $6.10. Example 2: If the doctor charges $85.00 for the service, the patient’s out-of-pocket cost before EMSN benefits are paid is $45.65 (doctor’s fee minus the MBS rebate received). The EMSN benefit for this service would be calculated to be $36.55 (80% of the out-of-pocket cost) however, as this item has an EMSN benefit cap, the patient will receive the cap amount of $32.55. As a result, the total cost incurred by the patient is $13.10. The EMSN benefit caps only apply to out-of-hospital services, as EMSN benefits are only paid for out-of-hospital services. The EMSN benefit caps do not impact on the amount patients receive through their private health insurance.

The full list of MBS items is available online on the MBS website. The website lists all the Medicare services and the associated MBS schedule fees and rebates for each item. The EMSN benefit cap will appear in the item description on MBS online, if the item has an EMSN benefit cap.

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Changes to Obstetrics and Assisted Reproductive Technology on 1 January 2010

With the introduction of EMSN capping on 1 January 2010, a number of structural changes were made to obstetrics and ART services, including the introduction of new items and changes to Medicare rebates and item descriptors. Some of these changes are outlines below:

Obstetrics

On 1 January 2010 two items for consultations relating to pregnancy, 16401 and 16404, were introduced into the obstetrics section of the MBS. These items have the same fee as specialist attendance items 104 and 105 however they carry an EMSN benefit cap. These items continue to be restricted to specialists.

The item for the planning and management of a pregnancy was split into two items. Item 16590 is claimable for planning and managing a pregnancy that has progressed beyond 20 weeks where the practitioner intends to perform the labour and delivery. Item 16591 is claimable for planning and managing a pregnancy that has progressed beyond 20 weeks where the practitioner does not intend to perform the labour and delivery.

With the introduction of capping the base Medicare rebates for 15 obstetrics items was increased at a cost of $157.6 million over four years. The Medicare rebates for obstetrics attendance items and labour and delivery items where increased by 10 per cent and 30 per cent respectively. In addition the Medicare rebate for item 16590 – planning and management of a pregnancy was increased significantly. This is of particular benefit to those women that do not qualify for EMSN benefits.

Assisted Reproductive Technology (ART)

With the introduction of capping, the Medicare items for ART services, including In-Vitro Fertilisation (IVF), were restructured in negotiation with the ART profession and patient group ACCESS. This structure better reflects current clinical practice. There are no restrictions on the number of ART cycles patients can have under Medicare.

Are the levels of the EMSN benefits caps indexed?

The EMSN benefit caps are indexed by Consumer Price Index (CPI) on 1 January each year. On 1 January 2012, the EMSN benefit caps increased by 3.6% (annual CPI as measured in the June quarter). The MBS Schedule fees and rebates for most MBS items are indexed on 1 November each year. This means that the maximum amount of Medicare benefits payable increases twice each year, once in January and once in November.

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Further information

For more information visit www.medicare.gov.au or contact Department of Human Services - Medicare:

Medicare
GPO Box 9822
in your capital city

Phone: 132 011 (local call rate) 24 hours 7 days a week.
Email: medicare@medicareaustralia.gov.au

Further background on the EMSN is also available of the Department of Health and Ageing website www.health.gov.au

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CAPPED ITEMS

EMSN benefit caps apply to the MBS items outlined below. The EMSN benefit caps outlined below are for the calendar year 2012.

Item number	Description	2012 EMSN benefit cap ($)
14201	Injection of poly-L-lactic acid for the treatment of severe facial lipoatrophy (initial session)	35.40
14202	Injection of poly-L-lactic acid for the treatment of severe facial lipoatrophy (subsequent sessions)	17.95
32500	Varicose vein treatment via injection of sclerosant	119.30
32520	Varicose vein treatment of one leg using endovenous laser therapy	76.35
32522	Varicose vein treatment of one leg using endovenous laser therapy	76.35
42702	Cataract surgery	108.45
45560	Hair Transplantation	162.65

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.

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Assisted Reproductive Technology

Item number	Description	2012 EMSN benefit cap ($)
13200	ART services - superovulated treatment cycle proceeding to oocyte retrieval – initial cycle in a calendar year	1,655.60
13201	ART services- superovulated treatment cycle proceeding to oocyte retrieval – subsequent cycle in a calendar year	2,403.30
13202	ART services – superovulated cycles that is cancelled prior to oocyte retrieval	64.15
13203	Ovulation monitoring services for artificial insemination	106.85
13206	ART services - natural treatment cycle or treatment cycle where oocyte growth & development is induced using oral medication only	64.15
13209	Planning and management of an ART treatment cycle	10.75
13210	Initiation of a professional attendance via videoconference, where that service relates to item 13209	5.20
13212	Oocyte retrieval	69.50
13215	Transfer of embryos to the female reproductive system	48.10
13218	Preparation of frozen or donated embryos	694.30
13221	Preparation of semen for artificial insemination	21.40
13251	Intracytoplasmic sperm injection	106.85

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.

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Obstetric services

Item number	Description	2012 EMSN benefit cap ($)
16399	Initiation of a professional attendance via videoconference, where that service relates to item 16401, 16404, 16406, 16500, 16590 or 16591	23.80
16400	Antenatal attendance by a nurse or midwife on the behalf of a medical practitioner	10.90
16401	Initial specialist attendance by a practitioner in the practice of obstetrics	54.25
16404	Subsequent specialist attendance by a practitioner in the practice of obstetrics	32.55
16406	32 to 36 week obstetric visit - Antenatal professional attendance, as part of a single course of treatment, at 32-36 weeks of the patient's pregnancy when the patient is referred by a participating midwife. Payable only once for a pregnancy.	106.85
16500	Antenatal attendance	32.55
16501	External Cephalic Version for Breech Presentation, After 36 Weeks	65.10
16502	Attendance for treatment of Polyhydramnios, Unstable Lie, Multiple Pregnancy, Pregnancy Complicated by Diabetes or Anaemia, Threatened Premature Labour Treated by Bed Rest Only or Oral Medication	21.70
16504	Attendance for the treatment of Habitual Miscarriage by Injection of Hormones Each Injection Up to a Maximum of 12 Injections	21.70
16505	Attendance for threatened Abortion, Threatened Miscarriage or Hyperemesis Gravidarum	21.70
16508	Attendance for Pregnancy Complicated by Acute Intercurrent Infection, Intrauterine Growth Retardation, Threatened Premature Labour With Ruptured Membranes or Threatened Premature Labour Treated by Intravenous Therapy	21.70
16509	Attendance for the treatment of Preeclampsia, Eclampsia or Antepartum Haemorrhage	21.70
16511	Purse String Ligation of Cervix	108.45
16512	Removal of Purse String Ligature of Cervix	32.55
16514	Antenatal Cardiotocography in the Management of High Risk Pregnancy	16.35
16515	Management of Vaginal Delivery As An Independent Procedure Where the Patient's Care Has Been Transferred by Another Medical Practitioner for Management of the Delivery	173.50
16518	Management of Vaginal Delivery As An Independent Procedure Where the Patient's Care Has Been Transferred by Another Medical Practitioner for Management of the Delivery	173.50
16519	Management of Labour and Delivery by Any Means (Including Caesarean Section) Including Post-partum Care for 5 Days	325.25

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.

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Item number	Description	2012 EMSN benefit cap ($)
16520	Management of Labour and Delivery by Any Means (Including Caesarean Section) Including Post-partum Care for 5 Days	325.25
16522	Management of complicated birth	433.70
16525	Management of Second Trimester Labour, With or Without Induction, for Intrauterine Fetal Death, Gross Fetal Abnormality or Life Threatening Maternal Disease	151.85
16527	Management of Vaginal Delivery, if the patient's care has been transferred by a participating midwife for management of the delivery, including all attendances related to the delivery. Payable once only for a pregnancy.	173.50
16528	CAESAREAN SECTION and post-operative care for 7 days, if the patient's care has been transferred by a participating midwife for management of the birth. Payable once only for a pregnancy.	325.25
16564	Evacuation of Retained Products of Conception (Placenta, Membranes or Mole) As a Complication of Confinement, With or Without Curettage of the Uterus	216.85
16567	Management of Postpartum Haemorrhage by Special Measures Such As Packing of Uterus	216.85
16570	Vaginal Correction of Acute Inversion of the Uterus	216.85
16571	Repair of Extensive Laceration or Lacerations of the Cervix	216.85
16573	Repair of Third Degree Tear, Involving Anal Sphincter Muscles and Rectal Mucosa	216.85
16590	Planning and Management of a Pregnancy That as Progressed Beyond 20 Weeks.	216.85
16591	Planning and Management of a Pregnancy where the care of the patient will be transferred to another medical practitioner for the labour and delivery	108.45
16600	Amniocentesis	32.55
16603	Chorionic villus sampling	65.10
16606	Fetal Blood Sampling From Umbilical Cord or Fetus	130.15
16609	Fetal Intravascular Blood Transfusion, Using Blood Already Collected, Including Neuromuscular Blockade, Amniocentesis and Fetal Blood Sampling.	249.40
16618	Amniocentesis, therapeutic	103.05
16624	Drainage of Fetal Fluid Filled Cavity	140.95
16627	Feto-amniotic Shunt, Insertion of, Into Fetal Fluid Filled Cavity, Including Neuromuscular Blockade and Amniocentesis	303.60
16633	Procedure On Multiple Pregnancies Relating to Items 16606, 16609, 16612, 16615 and 16627	227.75
16636	Procedure On Multiple Pregnancies Relating to Items 16600, 16603, 16618, 16621 and 16624	86.80

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.

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Pregnancy ultrasounds

Item number	Description	2012 EMSN benefit cap ($)
55700	Pregnancy related scan - less than 12 weeks referred patient	32.55
55701^		16.30
55703	Pregnancy related scan - less than 12 weeks non referred patient	16.35
55702^		8.20
55704	Pregnancy related scan - 12 to 16 weeks referred patient	38.00
55710^		19.05
55705	Pregnancy related scan - 12 to 16 weeks non referred patient	16.35
55711^		8.20
55706	Pregnancy related scan - 17 to 22 weeks referred patient	54.25
55713^		27.15
55707	Pregnancy related scan - rump length of 45 to 84mm referred patient	38.00
55714^		19.05
55708	Pregnancy related scan - rump length of 45 to 84mm non referred patient	16.35
55716^		8.20
55709	Pregnancy related scan - 17 to 22 weeks non referred patient	21.70
55717^		10.90
55712	Pregnancy related scan - 17 to 22 weeks referred patient by obstetrician	65.10
55719^		32.55
55715	Pregnancy related scan - 17 to 22 weeks non referred patient, performed by obstetrician	21.70
55720^		10.90
55718	Pregnancy related scan - after 22 weeks referred patient	54.25
55722^		27.15
55721	Pregnancy related scan - after 22 weeks referred patient by obstetrician	65.10
55724^		32.55
55723	Pregnancy related scan - after 22 weeks non referred patient	21.70
55726^		10.90
55725	Pregnancy related scan - after 22 weeks non referred patient, performed by obstetrician	21.70
55727^		10.90
55729	Duplex scanning after 24th week	16.35
55730^		8.20
55762	Pregnancy related scan - 17 to 22 weeks non referred patient which identifies multiple pregnancy	32.55
55763^		16.30

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.
^ Items introduced under the Capital Sensitivity measure announced in the 2009-10 Federal Budget and claimable from 1 July 2011 for services provided using aged equipment.

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Item number	Description	2012 EMSN benefit cap ($)
55764	Pregnancy related scan - 17 to 22 weeks referred patient which identifies multiple pregnancy, performed by obstetrician	86.80
55765^		43.45
55766	Pregnancy related scan - 17 to 22 weeks non referred patient which identifies multiple pregnancy, performed by obstetrician	32.55
55767^		16.30
55768	Pregnancy related scan - after 22 weeks referred patient which confirms multiple pregnancy	81.40
55769^		40.75
55770	Pregnancy related scan - after 22 weeks non referred patient which confirms multiple pregnancy	32.55
55771^		16.30
55772	Pregnancy related scan - after 22 weeks referred patient by obstetrician which confirms multiple pregnancy	86.80
55773^		43.45
55774	Pregnancy related scan - after 22 weeks referred patient which confirms multiple pregnancy performed by obstetrician	38.00
55775^		19.05

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.
^ Items introduced under the Capital Sensitivity measure announced in the 2009-10 Federal Budget and claimable from 1 July 2011 for services provided using aged equipment.

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Midwifery

Item number	Description	2012 EMSN benefit cap ($)
82100	Initial midwife attendance with a participating midwife - lasting at least 40 minutes	21.40
82105	Short antenatal attendance with a participating midwife - up to 40 minutes	16.10
82110	Long antenatal attendance with a participating midwife - lat least 40 minutes.	21.40
82115	Planning and management of pregnancy with a participating midwife that has progressed beyond 20 weeks lasting at least 90 minutes	53.45
82130	Short postnatal attendance with a participating midwife	16.10
82135	Long postnatal attendance with a participating midwife	21.40
82140	Six week postnatal attendance	16.10

#Note: Actual EMSN benefit received depends on the out-of-pocket cost incurred by a patient.

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