EMSN caps on Psychiatry consultations 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 all Psychiatry consultation items.

Page last updated: 25 October 2012

Extended Medicare Safety Net and EMSN capping Psychiatry items

(sub-group A.8 in the MBS)
Download PDF version of the factsheet (PDF 497 KB)
Download RTF version of the factsheet (RTF 127 KB)

This fact sheet provides information on the EMSN benefit caps from 1 November 2012 that were announced in the 2012-13 Budget for all psychiatry consultation items. Separate fact sheets provide more information about the Extended Medicare Safety Net (EMSN) and the Original Medicare Safety Net (OMSN) and how EMSN benefit capping applies to other items.

Why are there EMSN caps on psychiatry items?

EMSN benefit caps have been introduced for all consultation and attendance items. The caps on all consultation items are equal to 300 per cent of the Medicare Benefits Schedule (MBS) fee to a maximum of $500.

The introduction of EMSN benefit caps for consultations responds to a number of issues raised in the independent review of the safety net arrangements in 2009 and the independent review of EMSN benefit capping in 2011. The changes have been made to support the long term sustainability of the EMSN.

What are the caps on psychiatry items?

The EMSN benefit cap is 300 per cent of the MBS Fee up to $500. That is, the EMSN benefit payable will be up to three times the MBS Fee, up to a maximum of $500.

How will I be affected?

The majority of patients will not be affected. The caps placed on consultations are set generously; therefore the caps will only apply in the small number of 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.
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 306, a consultation with a psychiatrist between 45 and 75 minutes, has an MBS Fee of $183.65, an out of hospital MBS rebate of $156.15 and an EMSN benefit cap of $500.00.

Example A: No impact to patients due to EMSN caps
If the psychiatrist charges $225 for the consultation, the patient’s out-of-pocket cost before EMSN benefits are paid is $68.85 (doctor’s fee minus the MBS rebate received). Assuming the patient has reached the relevant EMSN threshold, the EMSN benefit for this consultation is calculated to be $55.10 (80 per cent of the patient’s out of pocket cost).

As the calculated EMSN benefit is below the EMSN benefit cap amount of $500.00 the patient will receive the full $55.10 in EMSN benefits. As a result, the total cost incurred by the patient is $13.75 and EMSN capping has no impact on the patient.

Example B: Impact to patients due to EMSN caps
If the psychiatrist charges $785 for the consultation, the patient’s out-of-pocket cost before EMSN benefits are paid is $628.85 (doctor’s fee minus the MBS rebate received). Eighty per cent of the out-of-pocket cost would be equal to $503.10. This amount is higher than the EMSN benefit cap of $500.00, therefore, assuming the patient has reached the relevant EMSN threshold, the maximum EMSN benefit that the patient will receive is $500.00. The total MBS benefit for this consultation is calculated to be $656.15 (MBS rebate plus the EMSN benefit cap). As a result, the total cost incurred by the patient is $128.85. The effect of the psychiatrist 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 to the psychiatry items?

Item NumberBrief description of serviceEMSN benefit cap (percentage of MBS fee up to $500) EMSN cap ($)
289Development of a treatment and management plan for autism or other pervasive developmental disorder300%500.00
291Assessment and management of a patient – more than 45 minutes duration300%500.00
293Review of management plan – 30-54 minutes duration 300%500.00
296Initial consultation – more than 45 minutes duration 300%500.00
297Initial consultation – more than 45 minutes duration - hospital300%500.00
299Initial consultation, home visit – more than 45 minutes duration300%500.00
300Consultation of less than 15 minutes300%130.05
302Consultation of between 15 and 30 minutes300%259.35
304Consultation of between 30 and 45 minutes 300%399.30
306Consultation of between 45 and 75 minutes300%500.00
308Consultation of more than 75 minutes 300%500.00
310Consultation of less than 15 minutes – where 50 services have been exceeded in a calendar year300%64.80
312Consultation of between 15 and 30 minutes – where 50 services have been exceeded in a calendar year300%130.05
314Consultation of between 30 and 45 minutes – where 50 services have been exceeded in a calendar year300%199.95
316Consultation of between 45 and 75 minutes – where 50 services have been exceeded in a calendar year300%275.85
318Consultation of more than 75 minutes – where 50 services have been exceeded in a calendar year300%319.80
319Attendance of more than 45 minutes of a patient diagnosed with a severe personality disorder 300%500.00
320Consultation of less than 15 minutes at a hospital300%130.05
322Consultation of more than 15 minutes to less than 30 minutes – hospital300%259.35
324Consultation of more than 30 to 45 minutes – at a hospital 300%399.30
326Consultation of 45 to 75 minutes – at a hospital300%500.00
328Consultation of more than 75 minutes – at a hospital.300%500.00
330Attendance of lee than 15 minutes – where provided somewhere other than a consulting room or hospital 300%238.65
332Consultation of between 15 and 30 minutes – where provided somewhere other than a consulting room or hospital300%373.95
334Consultation of between 30 and 45 minutes – where provided somewhere other than a consulting room or hospital300%500.00
336Consultation of between 45 and 75 minutes – where provided somewhere other than a consulting room or hospital300%500.00
338Consultation of more than 75 minutes – where provided somewhere other than a consulting room or hospital300%500.00
342Group psychotherapy of more than 1 hour duration 300%147.90
344Group psychotherapy of more than 1 hour duration – involving a family group of 3 patients 300%196.35
346Group psychotherapy of more than 1 hour duration – involving a family group of 2 patients300%290.40
348Consultation of between 20 and 45 minutes – where someone other than the patient is being interviewed 300%380.25
350Consultation of more than 45 minutes – where someone other than the patient is being interviewed300%500.00
352Consultation of not more than 20 minutes – where someone other than the patient is being interviewed, over a course of continuing management of a patient 300%380.25
353Telepsychiatry of less than 15 minutes duration300%171.60
355Telepsychiatry 15 minutes to 30 minutes 300%343.35
356Telepsychiatry 30 to 45 minutes300%500.00
357Telepsychiatry 45 to 75 minutes300%500.00
358Telepsychiatry more than 75minutes300%500.00
359Telepsychiatry review 30 to 45 minutes300%500.00
361Telepsychiatry – initial consultation less than 45 minutes300%500.00
364Follow up to Telepsychiatry – less than 15 minutes300%130.05
366Face to face Telepsychiatry follow up 15 minutes to 30 minutes300%259.35
367Face to face Telepsychiatry follow up 30 minutes to 45 minutes300%399.30
369Face to face Telepsychiatry follow up 45 minutes to 75 minutes300%500.00
370Face to face Telepsychiatry follow up more than 75 minutes300%500.00
Note: Amounts are correct to 5 cents due to rounding.