Extended Medicare Safety Net (EMSN) 011-43080020

The Extended Medicare Safety Net (EMSN) provides an additional benefit for eligible families and individuals who incur out-of-pocket costs for out-of-hospital services. Out-of-hospital services include General Practitioner (GP) and specialist attendances. Once the relevant annual threshold of out-of-pocket costs has been met, Medicare will pay for 80% of any future out-of-pocket (OOP) costs for out-of-hospital Medicare services for the remainder of the calendar year.

Individuals and families eligible and enrolled for Medicare and families registered as a family for the existing Medicare Safety Net (MSN) are eligible for EMSN.

The EMSN applies to all persons entitled to receive Medicare benefits, either individuals or families registered for MSN, other than those eligible under the Concessional Safety Net or Family Tax Benefit (Part A) Safety Net.

Individuals

Eligibility commences when the individual enrols for Medicare.

The additional Medicare Safety Net benefit is automatically paid when the Medicare Safety Net threshold is reached.

Families

Eligibility commences from the date the family is registered for the Medicare Safety Net. All family members must be enrolled for Medicare to be added to a Medicare Family Safety Net.

The additional benefit is paid when the Medicare Family Safety Net composition has been confirmed and the Medicare Safety Net threshold has been reached.

All members of a family registered for EMSN are eligible to receive additional benefits.

EMSN benefit capping means that for some Medicare Benefits Schedule (MBS) items there is a maximum amount of EMSN benefits payable regardless of the fee charged by the doctor.

An EMSN benefit cap has been applied to some Medicare Benefit Schedule (MBS) items since 1 January 2010.

From 1 January 2013, the calculation of the EMSN benefit cap changed.

Once a patient reaches the EMSN threshold, they are entitled to the Medicare benefit, plus whichever is the lower amount of either:

• EMSN benefit (80% of out-of-pocket costs)
• EMSN percentage cap (when applicable and may vary between item numbers)
• EMSN maximum cap (when applicable and may vary between item numbers)

The capping amounts for item numbers can be found on the Medicare Benefits Schedule (MBS).

EMSN benefit caps apply to the following items:

• Consultations
• Allied Health
• ART (Assisted Reproductive Technology)
• Obstetrics
• Midwifery
• Pregnancy ultrasounds

A multiple operation is where 2 or more procedures, listed in Group T8 of the Medicare Benefits Schedule (MBS) (other than Subgroup 12 of that Group), are performed on a patient on the 1 occasion.

The Health Insurance Amendment (Extended Medicare Safety Net) Act 2012 allows items that are part of a multiple operation with a date of service on or after 12 October 2012 to be capped.

The Resources page contains a link to further information on processing a patient claim for a multiple operation where the EMSN cap is less than 80% of out of pocket expenses.

See also:

• Family registration and confirmation for Medicare Safety Net
• Medicare Safety Net thresholds
• Multiple operations assessing rules in Medicare

Where the item is subject to an EMSN benefit cap, the 20% of the out-of-pocket (OOP) expense paid by the claimant may not be sufficient to pay the account in full. The account is therefore treated as unpaid.

Service Officers are not expected to manually calculate the percentage amounts for the EMSN benefit cap. The caps are automatically calculated by the system and are applied at the time of processing the claim.

Service Officers must:

• be able to explain when an EMSN benefit cap applies
• not separate paid accounts where the patient is crossing the threshold (where possible)
• allow the system to calculate and pay the maximum Medicare Safety Net benefit

From 1 January 2004, out-of-pocket (OOP) expenses accumulate towards the Safety Net thresholds for individuals and registered Medicare Safety Net (MSN) families.

Service Officers can view:

• An individual's OOP expense totals on the Patient Claims History screen (NHSI, Medicare card number and [Shift F6])
• A family's OOP expenses on the Consumer Directory Maintenance System (CDMS). Select Medicare Safety Net program, key Medicare card number or Consumer ID or Medicare Personal Identification number (PIN).

When an EMSN family contains a concessional individual, the concessional individual's OOP expenses still accumulate towards the family's EMSN.

When the concessional individual meets the CSN threshold they are paid the additional benefits (that is, an additional 80% of the OOP expenses or the EMSN benefit cap) and the remaining 20% OOP expenses still contribute to the family's EMSN.

The gap (difference between Medicare benefit and the Schedule Fee) still accumulates towards the MSN.

The EMSN reimburses either:

• 80% of OOP expenses, or
• the EMSN benefit cap

Whichever is less for out-of-hospital services for individuals and families that meet the Safety Net criteria.

The OOP expense is the difference between the Medicare benefit and the total amount the doctor charges for services listed in the Medical Benefits Schedule (MBS) which are performed out-of-hospital.

Where an account has been paid in full, the system processes fully paid accounts automatically and calculates the correct benefit payable to the claimant.

Where an account is unpaid, the system produces a Pay Doctor via Claimant (PDVC) cheque for the standard Medicare benefit. The claimant is required to verify (substantiate) the OOP expense amount to be entitled to an additional benefit.

To reduce upfront costs to patients who have reached a Medicare Safety Net threshold, legislation allows claimants to only pay a maximum of 20% of the out-of-pocket (OOP) expense at the time of consultation.

Where exactly 20% of the OOP expense has been paid at the time of consultation, and the patient has reached the threshold, Services Australia will accept and process the claim. Where more than 20% of the OOP expense has been paid at the time of consultation, the system will determine based on the partial payment, to split the benefit or generate a Pay Doctor via Claimant (PDVC).

Note: where the item is subject to an 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.

This section provides scenarios to explain how to calculate the EMSN benefit payable for consultations and non-consultation items.

Note: Service Officers can access QITI in mainframe to determine whether an item number has an EMSN benefit cap applied to it. QITI will display the EMSN percentage cap and EMSN maximum cap, where applicable.

To access item number information in the mainframe type QITI, item number, date of service, press [Enter], then press [F5].

The Resources page includes a link to the MBS items which will have an Extended Medicare Safety Net cap from 1 November 2012 on the Department of Health and Aged Care website.

The Medicare Safety Net benefit for consultation items is the lesser of either:

• 80% of out-of-pocket (OOP) expenses
• the EMSN percentage cap (for example 300% of schedule fee)
• the EMSN maximum cap of $500.00

The Resources page contains examples to assist with working out the Medicare Safety Net benefits for consultation items.

The Medicare Safety Net benefit for non-consultation items is the lesser of:

• 80% of the out-of-pocket (OOP) expenses
• the EMSN percentage cap (for example 80% of the schedule fee)

Note: the EMSN maximum cap only applies to consultation items.

The Resources page contains examples to assist with working out the Medicare Safety Net benefits for non-consultation items.