Medicare Safety Net 011-43080000

The Medicare Safety Net is designed to provide assistance to people with high out-of-hospital medical expenses. The Medicare Safety Net applies to individuals or members of registered families and is calculated on a calendar year basis provided receipts are produced.

The Medicare Safety Net threshold is indexed annually from 1 January and operates on a calendar year, 1 January to 31 December.

To be eligible for the Medicare Safety Net, persons must be eligible and enrolled for Medicare and families must be registered for the Medicare Safety Net.

On 29 March 2004, three components of the Medicare Safety Net were introduced into the MedicarePlus Health Package:

• Concessional Safety Net (CSN)
• Family Tax Benefit (Part A) Safety Net (FTB(A))
• Extended Medicare Safety Net (EMSN)

In addition, the following changes were also introduced as part of the new components:

• accumulation of out-of-pocket (OOP) expenses towards the new thresholds
• partially paid accounts and the need to capture where a partial payment is made by the claimant
• split payments - benefits to practitioners and claimants from the one claim
• a new Medicare Safety Net registration system

Note: these new Safety Nets operate in addition to the existing Medicare Safety Net.

For Safety Net purposes, practitioners must provide the following information on accounts to indicate when the service occurred and whether the claim was fully paid, unpaid or partially paid:

• date
• amount charged
• total amount paid
• amount outstanding

The difference between the benefit paid for the service and the schedule fee (in the Medicare Benefits Schedule) is known as the gap amount. Medicare benefits are paid at 85% of the schedule fee for out-of-hospital services except for General Practitioner services. The 85% benefit level applies to all schedule fees up to the maximum patient gap (indexed annually on 1 November) payable for any service.

For eligible persons, when the total of all patient gap amounts for eligible out-of-hospital medical services reaches the Medicare Safety Net threshold amount (indexed annually from 1 January), Medicare benefits are payable at 100% of the schedule fee for out-of-hospital services during the remainder of the calendar year.

Where the total out of pocket (OOP) expenses for eligible out-of-hospital medical services reaches the Medicare Safety Net threshold amount (indexed annually from 1 January), Medicare benefits are increased to include an additional 80% (only when the patient has paid at least 20% of the OOP) of the OOP expense or the Extended Medicare Safety Net (EMSN) benefit cap for the remainder of the calendar year. See Medicare Safety Net thresholds for more information.

Accumulation and payment of the Medicare Safety Net benefits are based on date of lodgement of a claim and not the date of service.

When a paid account is processed, the patient's contribution paid will be automatically recorded on the system, based on the Medicare claim content entered from the Medicare claim account.

When an unpaid account is processed for payment of a Medicare benefit and a 'pay doctor via claimant' cheque is issued, it is then the patient's responsibility to subsequently provide evidence or declaration and proof of payment of the patient contribution, whichever is applicable.

If a patient presents a receipt showing that they have paid the difference between the benefit and the charge, the gap can be substantiated immediately so that this amount accrues towards the patient's Safety Net.

The minimum gap payment required for substantiation is 20% of the out of pocket (OOP) expenses.

Note: where the item is subject to an Extended Medicare Safety Net (EMSN) benefit cap the 20% of the OOP expense paid by the claimant may not be sufficient to pay the account in full and the account will be treated as an unpaid account.

If a member of a family or an individual requests a list of unverified payments (unsubstantiated services) for themselves or an eligible family member, the list will be provided in a letter sent to the individual 14 years and over (to protect their privacy). Where the requester is the Family Contact (FC) or Spouse (SP), the list of subjects will contain any dependents under 14 years of age. This letter is referred to as Letter U.

If a customer updates their family safety net due to a change in circumstances such as separating from a relationship, there are other key tasks they should consider to keep their personal information safe. See Separating safely - protecting personal details.

From 1 January 2009, families covered by the Medicare Safety Net include same-sex couples and their dependants. This provides the same access to Medicare Safety Net for all couples, regardless of gender. The same Medicare Safety Net rules for thresholds and concessions applies to these families.

From 9 December 2017, this also extends to same-sex couples who are married.

Note: prior to the implementation of these changes, same-sex couples were not recognised as families for Medicare Safety Net purposes.

Service Officers may receive enquiries from a person where Services Australia has not recognised an individual's concessional or Family Tax Benefit (Part A) eligibility.

Where a claimant is present in a service centre, and believes they have an entitlement that has not been identified by Services Australia, Service Officers must follow the Operator Checklist for Medicare Safety Net enquiries to resolve the matter immediately.

Centrelink transmits data to Medicare for concessional or Family Tax Benefit (Part A) status checking.

In some cases, data may not match due to various reasons, such as, differences in spelling or shortening of names. If records cannot be matched for Family Tax Benefit (Part A) data when the data is received by Medicare, a message is sent back to Centrelink advising them of this. Centrelink then requests from the client (via letter) their Medicare number and subsequent release of their Medicare number to Medicare.

Only details of the individual recipient of a Family Tax Benefit (Part A) payment are transmitted to Medicare. Medicare then match this to the family registration. If the family of the recipient is not registered, the out-of-pocket (OOP) expenses will accrue to $2,000 Extended Medicare Safety Net for that individual.

Medicare Safety Net threshold information for both individuals and families can be checked via the ‘Medicare Safety Net Threshold details’ tab of the CDMS Inquire Medicare Safety Net Details screen.

See also: Family registration and confirmation for Medicare Safety Net and Medicare Safety Net thresholds.