Extended Medicare Safety Net (EMSN) 011-43080020

Examples of Medicare Safety Net calculations

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

Item

How to work out…

1

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 reached for consultation item 23 - Scenario 1 - 80% OOP, EMSN percentage cap, maximum cap MSN when claiming consultation item 36 - Scenario 2 Calculating the Medicare Safety Net threshold reached for consultation item 36 - Scenario 2 - 80% OOP, EMSN percentage cap, 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

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.

When processing a patient claim for a multiple operation where…	then the EMSN benefit cap…
all items within the group have an EMSN benefit cap	applies to all items.
not all items within the group have an EMSN benefit cap	does not apply to any items.

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.

Component	Amount
Schedule fee for item 23	$36.30
Medicare benefit for item 23 (100% of schedule fee)	$36.30
Provider charged Anne	$200.00

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.

80% of out-of-pocket (OOP) expenses	EMSN percentage cap (when applicable)	EMSN maximum cap (when applicable)
Charge - Medicare benefit = OOP OOP x 80% =	EMSN percentage cap for item 23 is 300% Schedule fee x 300% =	This is displayed on QITI.
Calculation for Anne: $200.00 - $36.30 = $163.70 $163.70 x 80% = $131.00	Calculation for Anne: $36.30 x 300% = $108.90	Maximum cap for item 23 is $500.00

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.

Component	Amount
Schedule fee for item 36	$70.30
Medicare benefit for item 36 (100% of schedule fee)	$70.30
Provider charged Bob	$150.00

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.

80% of out-of-pocket (OOP) expenses	EMSN percentage cap (when applicable)	EMSN maximum cap (when applicable)
Charge - Medicare benefit = OOP OOP x 80% =	EMSN percentage cap for item 36 is 300% Schedule fee x 300% =	This is displayed on QITI.
Calculation for Bob: $150.00 - $70.30 = $79.70 $79.70 x 80% = $63.80 (normal rounding rules apply)	Calculation for Bob: $70.30 x 300% = $210.90	Maximum cap for item 36 is $500.00

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.

Component	Amount
Schedule fee (SF) for item 30071 (Benefit paid for item 30072 is 85%)	$52.20
Provider charges Igor	$90.00 per item

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.

Factors affecting the Medicare Benefits Schedule (MBS) fee	Medicare benefit - 85% of the Medicare schedule fee (SF)	Medicare Safety Net benefit - 80% of the customer's out-of-pocket (OOP) amount	Medicare Safety Net benefit - EMSN percentage cap (80% of the new SF)	Total Medicare benefit calculation
SF for the first item is $52.20	$44.40	Igor's charge - total Medicare benefit x 80%	$41.80	Medicare Benefit + EMSN percentage cap
SF for the second item is $26.10	$22.20	Igor's charge - total Medicare benefit x 80%	$20.90	Medicare Benefit + EMSN percentage cap
Totals	$66.60	$90.75	$62.70	$129.30

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.

Component	Amount
SF for item 32500	$109.80
SF for item 31205	$95.45
Charge	$250.00 per item

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.

Factors affecting the Medicare Benefits Schedule (MBS) fee	Medicare benefit - 85% of the Medicare schedule fee (SF)	Medicare Safety Net benefit - 80% of the customer's out-of-pocket (OOP) amount	Medicare Safety Net benefit - percentage cap	Medicare Safety Net benefit - EMSN percentage cap (110% of the new SF)	Total Medicare benefit calculation
SF for the first item (32500) is $109.80	$93.35	Jill's charge - total Medicare benefit x 80% ($250 - $93.35 x 80% = $125.32)	110%	$120.80 ($109.80 x 110%)	Medicare Benefit + EMSN percentage cap ($93.35 + $120.80)
SF for the second item (31205) is $47.75	$40.60	Jill's charge - total Medicare benefit x 80% ($250 - $40.60 X 80% = $167.52)	80%	$38.20 ($47.75 x 80%)	Medicare Benefit + EMSN percentage cap $40.60 + $38.20)
Totals	$133.95	$292.85		$159.00	$292.95

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.

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Frequently Asked Questions about changes to EMSN benefit caps

Current EMSN caps on ART and Obstetrics

MBS items which will have an Extended Medicare Safety Net cap from 1 November 2012

Health Budget 2012-2013 - Access to Medicare Services (Health) - for information on item capping