Extended Medicare Safety Net (EMSN) 011-43080020

Examples of Medicare Safety Net calculations

Multiple operations and EMSN benefit cap - Examples of when the EMSN benefit cap applies

MSN when claiming consultation item 23 - Scenario 1

Calculating the Medicare Safety Net threshold for consultation item 23 - Scenario 1 - 80% OOP, EMSN percentage cap, EMSN maximum cap

MSN when claiming consultation item 36 - Scenario 2

Calculating the Medicare Safety Net threshold for consultation item 36 - Scenario 2 - 80% OOP, EMSN percentage cap, EMSN maximum cap

EMSN safety net benefit for non-consultation item 30071 - Scenario 1

Options for Medicare Safety Net benefit for non-consultation items - Claiming non-consultation item 30071

Claiming non-consultation items 32500 and 31205 - Scenario 2

Medicare Safety Net benefit for non-consultation item 32500 and 31205 - Scenario 2

Basic Medicare Safety Net examples

Examples of Medicare Safety Net calculations

Table 1: This table contains a list of Medicare Safety Net calculations.

Multiple operations and EMSN benefit cap - Examples of when the EMSN benefit cap applies

Table 2: This table provides examples of when the EMSN benefit cap would apply. Note: this table only applies where the EMSN benefit cap is less than the 80% of OOP expenses.

MSN when claiming consultation item 23 - Scenario 1

Table 3: This table provides an example of how to work out the Medicare Safety Net benefit when claiming consultation item 23. Anne submits a claim for a paid account for item 23.

Note: as Anne has reached the relevant threshold and is entitled to the Medicare benefit plus the Medicare Safety Net benefit. Three components need to be considered when working out the Medicare Safety Net benefit. Anne will receive the lesser amount of the 3. See example below (scenario 1) for Safety Net threshold reached for consultation item 23 to calculate Anne's Medicare safety net component.

Calculating the Medicare Safety Net threshold for consultation item 23 - Scenario 1 - 80% OOP, EMSN percentage cap, EMSN maximum cap

Table 4: This table provides an example of how to work out the Medicare Safety Net benefit including calculating the EMSN capping.

Note: Anne's Medicare Safety Net benefit is the lesser of the 3 options above which is $108.90. Anne would receive the Medicare benefit of $36.30 + the EMSN percentage cap of $108.90 = total benefit of $145.20.

MSN when claiming consultation item 36 - Scenario 2

Table 5: This table provides an example of how to work out the Medicare Safety Net benefit when claiming consultation item 36. Bob submits a claim for a paid account for item 36.

Note: Bob has reached the relevant threshold and is entitled to the Medicare benefit plus the Medicare Safety Net benefit. Three components need to be considered when working out the Medicare Safety Net benefit, and Bob will receive the lesser amount of the 3. See example (scenario 2) safety net threshold reached for consultation item 36.

Calculating the Medicare Safety Net threshold for consultation item 36 - Scenario 2 - 80% OOP, EMSN percentage cap, EMSN maximum cap

Table 6: This table provides an example of how to work out the 3 components for Bob's Medicare Safety Net benefit.

Note: Bob's Medicare Safety Net benefit is the lesser of the 3 options above which is $63.80. Bob would receive the Medicare benefit of $70.30 + 80% of the OOP which is $63.80 = total benefit of $134.10.

EMSN safety net benefit for non-consultation item 30071 - Scenario 1

Table 7: This table provides an example of how to work out Igor's multiple operation, claiming items 30071 x 2. Igor has fully paid the account.

Options for Medicare Safety Net benefit for non-consultation items - Claiming non-consultation item 30071

Table 8: This table provides an example of how to work out Igor's Medicare Safety Net benefit when claiming non-consultation item 30071.

Note: as the EMSN percentage cap amount is less than the 80% OOP, the Medicare Safety Net benefit would be $62.70. Igor would receive the Medicare benefit of $66.60 + the EMSN percentage cap of $62.70. Igor would receive a total benefit of $129.30.

Claiming non-consultation items 32500 and 31205 - Scenario 2

Table 9: This table provides an example of how to work out Jill's Medicare Safety Net benefit when claiming consultation items 32500 and 31205.

Medicare Safety Net benefit for non-consultation item 32500 and 31205 - Scenario 2

Table 10: This table provides an example of how to work out Jill's Medicare Safety Net benefit when claiming non-consultation item 32500 and 31205.

Note: as the EMSN percentage cap amount is less than the 80% OOP, the Medicare Safety Net benefit would be $159.00. Jill would receive the Medicare benefit of $133.95 + the EMSN percentage cap of $159.00. Jill would receive a total benefit of $292.95.

Basic Medicare Safety Net examples

• Doctors charge for an item 23 $55.00
• Medicare benefit $31.45
• Patient OOP $23.55

The OOP expenses do not include costs for items such as the hire of equipment (for example, crutches), medicines, bandages or travel expenses incurred to attend a consultation etc.

Calculating Medicare Safety Net - example

• Doctors charge for an item 23 $55.00*
• Medicare benefit $31.45
• Patient OOP $23.55
• 80% of OOP $18.85 Safety Net benefit (rounded up)

*The account has been fully paid.

The claimant will receive a total Medicare benefit of $31.45 + $18.85 = $50.30, leaving them with a total OOP expense of $4.70 (20% of OOP expense).

When the item is subject to an EMSN benefit cap of $10 instead of the 80% of OOP, the claimant will receive a total Medicare benefit of $31.45 + $10 = $41.45, leaving them with a total OOP expense of $13.55.