Medicare Safety Net thresholds 011-43080100

A Safety Net threshold is a dollar amount that an individual or a registered family must reach in eligible out-of-pocket medical costs before they become entitled to receive Safety Net benefits.

These thresholds vary if the:

• person is an individual (single) or part of a family not receiving a commonwealth concession or Family Tax Benefit part A, or
• individual or family receives a Commonwealth concession or Family Tax Benefit Part A entitlement

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

There are 4 components of the Medicare Safety Net and threshold amounts are indexed annually from 1 January:

• Original (Gap) for all Medicare card holders, is the difference between the benefit paid and the schedule fee. This amount accumulates towards the threshold. When the threshold is reached Medicare benefits are payable at 100% of the schedule fee for out-of-hospital services
• Extended Family Tax Benefit (FTB) for families eligible for FTB Part A is the difference between the charge and the benefit paid (out-of-pocket expenses (OOP)) for out-of-hospital services. This amount accumulates towards the threshold. When the threshold is reached Medicare benefits are payable at 80% of the OOP expenses or the benefit cap, whichever is the lesser amount. See also: Family Tax Benefit Part A in Medicare Safety Net
• Extended Concessional for Commonwealth concession card holders is the difference between the charge and the benefit paid (OOP) for out-of-hospital services. This amount accumulates towards the threshold. When the threshold is reached Medicare benefits are payable at 80% of the OOP expenses or the benefit cap, whichever is the lesser amount. See also: Concessional Safety Net (CSN) threshold for Medicare
• Extended General for all Medicare card holders is the difference between the charge and the benefit paid (OOP) for out-of-hospital services. This amount accumulates towards the threshold. When the threshold is reached Medicare benefits are payable at 80% of the OOP expenses or the benefit cap, whichever is the lesser amount
• Extended Medicare Safety Net (EMSN) Benefit Cap - 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. See also: Extended Medicare Safety Net (EMSN)

The Resources page contains a table that lists the Medicare Safety Net threshold amounts.

When the eligible out-of-hospital services reach the Safety Net threshold for that year (family or individual), and for families their composition has been confirmed, the Medicare benefits are increased. This may vary for reaching the Family Tax Benefit (FTB) Part A concessional threshold, refer to Family Tax Benefit Part A in Medicare Safety Net for more information on FTB A concessional threshold.

This applies to individuals or families who are registered in a family Safety Net and the total gap amounts and the total out-of-pocket (OOP) expenses paid during a calendar year for eligible out-of-hospital services reach the Safety Net threshold for that year (family or individual). When the eligible threshold is met Medicare benefits are increased depending on which threshold has been reached.

For the original Safety Net, benefits will increase to 100% of the schedule fee and for the Concessional Safety Net (CSN), Family Tax Benefit (FTB) Part A and Extended General Medicare Safety Net (EMSN) benefits will increase to include 80% of the OOP expenses or the EMSN benefit cap.

All claims lodged after the date of a family registration will contribute towards the threshold, however a family composition must be confirmed before higher benefits will be paid. Once the threshold has been reached and the family is confirmed, higher benefits will be paid for all members of the registered family for the rest of the calendar year (this may vary for FTB A concessional, refer to Family Tax Benefit Part A in Medicare Safety Net).

If the family is not confirmed, all members are treated as individuals for Safety Net purposes.

When a registered family’s OOP expenses are equal to or greater than 70% of the threshold, the family contact (FC) gets a letter (Letter F) that tells them to confirm the family composition. This occurs each calendar year.

If the FC has electronic messaging, a message is sent to their myGov inbox. See: Family registration and confirmation for Medicare Safety Net > Medicare Safety Net confirmation.

All out-of-hospital services with a date of service before and after the date of registration will be counted towards the threshold amount, however no additional benefits are paid for services performed prior to the family registration date. Individuals do not have to register for the Medicare Safety Net and out of pocket expenses for out-of-hospital services processed will automatically contribute to the relevant threshold.

Customers registered as an individual, or as the family contact (FC) or spouse/partner (SP) of a Medicare Safety Net family can view their Medicare Safety Net balance using their Medicare online account.

See: Using Medicare self service.

A person who leaves a registered family and has a Safety Net amount in their own right will take this amount with them to their individual safety net.

If a person transfers from one registered family to another registered family prior to family confirmation, they take their individual Safety Net amount with them. This amount is then deducted from the first registered family Safety Net amount and added to the new registered family Safety Net amount.

If a family Safety Net composition has been confirmed a person cannot leave the family safety net until the next calendar year. A person can only leave a family Safety Net providing the family Safety Net composition has not been confirmed.

For example, a person who leaves a registered family with an individual Safety Net amount of $100 will take a Safety Net amount of $100 with them and this $100 will be deducted from the accumulation of the family being left.

Where a claim is processed that will take an individual or family over any of the eligible Safety Net thresholds, the system will automatically calculate and pay the additional benefit under the Safety Net for individual or a confirmed family.

Where a claim is processed that will take an individual or family over, or near the current threshold, the system checks for the entitlement status to determine whether the individual or family is eligible for the Concessional Safety Net (CSN) or Family Tax Benefit (FTB) Part A Safety Net. Medicare receives entitlement information from Centrelink.

Entitlement status confirmed

If the system has registered a concessional or FTB Part A entitlement status and the family is confirmed and the claim has been assessed, the system will automatically calculate and pay the additional benefit under the Concessional or FTB Part A Safety Net.

Entitlement status not confirmed

If the system does not have registered a concessional or FTB Part A entitlement status, the system will continue to accumulate the OOP expenses to the Extended Medicare Safety Net (EMSN) threshold amount.

Where an individual or registered family reaches the current threshold for out-of-hospital services, except GP services, the standard Medicare benefit will increase from 85% to 100% of the schedule fee for the remainder of the calendar year.

The system sends a confirmation letter to families when their gap amount is equal to 70% of the threshold.

When out-of-pocket (OOP) expenses reach the current threshold amount for an individual or family who is not entitled to the Concessional Safety Net (CSN) or Family Tax Benefit (FTB) Part A Safety Net, the individual or family will be entitled to additional benefits under the Extended Medicare Safety Net (EMSN).