Extended Medicare Safety Net and EMSN capping GP consultation items (for example, sub-groups A.1, A.11, A.15 and A.20 in the MBS)

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This fact sheet provides information on the EMSN benefit caps from 1 November 2012 that were announced in the 2012-13 Budget for all GP 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 GP consultation items?

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

The introduction of EMSN benefit caps on consultations responds to a number of issues raised in the independent review of 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 do 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.

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; 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 23, a Level B consultation with a GP, has an MBS Fee of $36.30, an out of hospital MBS rebate of $36.30 (100% of MBS Fee for GP services) and an EMSN benefit cap of $108.90. Example A: No impact to patients due to EMSN caps If the doctor charges $80 for the consultation, the patient’s out-of-pocket cost before EMSN benefits are paid is $43.70 (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 $35.00 (80 per cent of the patient’s out-of-pocket cost). As the calculated EMSN benefit is below the EMSN benefit cap amount of $108.90, the patient will receive the full $35.00 in EMSN benefits. As a result, the total cost incurred by the patient is $8.70 and EMSN capping has no impact on the patient. Example B: Impact to patients due to EMSN caps If the doctor charges $280 for the consultation, the patient’s out-of-pocket cost before EMSN benefits are paid is $243.70 (doctor’s fee minus the MBS rebate received). Eighty per cent of the out-of-pocket cost would be equal to $195.00. This amount is higher than the EMSN benefit cap of $108.90, therefore, assuming the patient has reached the relevant EMSN threshold, the maximum EMSN benefit that the patient will receive is $108.90. The total MBS benefit for this consultation is calculated to be $145.20 (MBS rebate plus the EMSN benefit cap). As a result, the total cost incurred by the patient is $134.80 and EMSN capping 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 GP consultation items?

Note: All GP consultation items will have an EMSN benefit cap, but only the more commonly claimed GP items have been included in this table.

GP Attendances

Item Number	Brief description of service	EMSN benefit cap (percentage of MBS fee up to $500)	EMSN cap ($)
3	Level A consultation at consulting Rooms	300%	49.80
23	Level B consultation at consulting rooms	300%	108.90
36	Level C consultation at consulting rooms	300%	210.90
44	Level D consultation at consulting rooms	300%	310.50

Urgent Attendance after hours

Item Number	Brief description of service	EMSN benefit cap (percentage of MBS fee up to $500)	EMSN cap ($)
597	After hours consultation between 7am and 11pm	300%	381.75
599	After hours consultation between 11pm and 7am	300%	450.00

GP Management Plan

Item Number	Brief description of service	EMSN benefit cap (percentage of MBS fee up to $500)	EMSN cap ($)
721	Preparation of a GP Management Plan	300%	424.20
723	Coordinate team care arrangements	300%	336.15
729	Contribution to a multidisciplinary care plan or review of a multidisciplinary care plan prepared by another provider	300%	207.00
731	Contribution to a multidisciplinary plan for patient in a residential aged care facility or review of such plan	300%	207.00
732	Review GP management plan or coordination a review of team care arrangements	300%	211.95

GP Mental Health Plan

Item Number	Brief description of service	EMSN benefit cap (percentage of MBS fee up to $500)	EMSN cap ($)
2700	Preparation of mental health plan lasting at least 20 minutes without mental health skills training	300%	207.00
2701	Preparation of mental health plan lasting at least 40 minutes without mental health skills training	300%	304.65
2712	Review a GP mental health plan or a psychiatrist assessment and management plan	300%	210.90
2713	Consultation in relation to mental disorder at least 20 minutes	300%	210.90
2715	Preparation of mental health plan lasting at least 20 minutes with mental health skills training	300%	267.75
2717	Preparation of mental health plan lasting at least 40 minutes with mental health skills training	300%	394.35
2721	Provision of focussed psychological strategies at least 30 minutes, surgery consultation	300%	272.85
2725	Provision of focussed psychological strategies at least 40 minutes, surgery consultation	300%	390.45

Note: Amounts are correct to 5 cents due to rounding.