PDF version Medicare Safety Net Arrangements - 1 January 2023 (PDF 114 KB)
Word version Medicare Safety Net Arrangements - 1 January 2023 (Word 123 KB)

2023 Medicare Safety Net Threshold Amounts

Safety Net	Concessional individuals and families*	Non-concessional individuals and families
Original Medicare Safety Net (OMSN)	$531.70	$531.70
Extended Medicare Safety Net (EMSN)	$770.30	$2,414.00

*Concessional individuals and families are those that are Commonwealth concession cardholders and/or families who receive Family
Tax Benefit (Part A)

OMSN and EMSN thresholds are indexed annually on 1 January in line with the CPI (September Quarter)

What is the Original Medicare Safety Net?

The Original Medicare Safety Net (OMSN) works in conjunction with the Extended Medicare Safety Net (EMSN). Under the OMSN, once your gap expenses reach the threshold in a calendar year, Medicare will reimburse you 100% of the Medicare Benefits Schedule (MBS) fee (instead of 85%). This only applies to out-of-hospital medical services that are listed on the MBS and that you receive for the remainder of the calendar year. Only the ‘gap amount’ counts towards the OMSN threshold. The ‘gap amount’ is the difference between the Medicare rebate and the MBS fee. If your health practitioner charges more than the schedule fee, you may still incur an out-of-pocket cost.

Individuals do not need to register and will automatically receive the higher rebate once the threshold is reached. Families need to register with Services Australia, in order for family members’ expenses to collectively accumulate towards the threshold.

What is the Extended Medicare Safety Net?

The EMSN provides an increased rebate for Australian families and individuals who incur out-of-pocket costs for Medicare eligible out-of-hospital services. Once the relevant annual threshold of out-of-pocket costs has been met, Medicare will pay up to 80 per cent of any future out-of-pocket costs for out-of-hospital Medicare services for the remainder of the calendar year. However, there is an upper limit on the amount of benefit that can be paid under the EMSN for a small number of Medicare services.

Couples and families should contact Services Australia to register their family members as part of a safety net eligible family. Registering as a family allows eligible out-of-pocket costs for each individual family member to count towards the family’s EMSN threshold. Couples and families need to register even if all family members are listed on the Medicare card. Registration is only required once, unless family members change, for example, if a student child is no longer studying full time or you have a newborn baby.

What are out-of-hospital services?

Out-of-hospital services include general practitioner (GP) and specialist attendances, services provided in private clinics and private emergency departments, and many pathology and diagnostic imaging services. However, many day surgery facilities are classified as hospitals in Australia. The distinction between in-hospital and out-of-hospital services is not always obvious. It is important that patients talk with their GP/specialist regarding the classification and likely out-of-pocket costs for their medical treatment, including any rebates paid through Medicare.

What services are not eligible?

In-hospital services and services not listed on the MBS are not eligible for the EMSN. Any out-of-pocket costs incurred for such services will not count towards the safety net thresholds.

Only verified costs count towards the threshold. Verified costs are when you pay your doctor’s fee before you claim from us. If you have unverified costs, you’ll need to pay them before they will count towards your threshold. Unverified costs are when you don’t pay your doctor’s fee before you claim from us. When this happens, your gap amount and out-of-pocket costs do not count towards your safety net thresholds. More information can be found on Services Australia’s website.

What is EMSN benefit capping?

The EMSN benefit cap is the maximum amount of EMSN benefits payable for an MBS item regardless of the fee charged by the health practitioner. Once the EMSN threshold is reached, you will receive either 80% of your out-of-pocket costs back or the EMSN cap amount, whichever is the lower amount.

The Health Insurance (Extended Medicare Safety Net) Determination 2017 is the legislative instrument that provides the Minister for Health and Aged Care with the ability to apply maximum increases (caps) in Medicare benefits under the EMSN.

Why are some services capped?

The EMSN is intended to be a patient benefit, providing additional support for patients who incur high out-of-pocket costs. It is not intended to be a mechanism for doctors to increase their fees.

Two independent, legislated reviews of the EMSN were conducted in 2009 and 2011. These reviews concluded that EMSN benefits were highly concentrated in certain types of services, including Assisted Reproductive Technology and obstetric services. In addition, a large portion of EMSN benefits were flowing to providers, via inflated fees, rather than to patients to assist with out-of-pocket costs.

In response to these reviews, EMSN caps were added to certain items. This includes caps being added for all consultation attendance items (including GP, specialist, consultant physician, and allied health consultations) as well as for select procedural items. Attendance items are capped at 300% of the MBS fee or $500, whichever is the lower amount. Procedural items can be capped as either a fixed amount or as a percentage of the MBS fee.

Caps have been progressively added to new items that are introduced to the MBS, in line with the existing policy authority.

How do I calculate my EMSN benefit?
For a capped item the method for determining the EMSN benefit is the same. Once the EMSN threshold is reached, you will receive either 80% of your out-of-pocket costs back or the EMSN cap amount, whichever is the lower amount.

Out-of-pocket cost is the difference between the fee charged by the GP/Specialist and the standard Medicare rebate received by the patient from Medicare before EMSN benefits are paid.

The following scenario and examples illustrate how the EMSN caps work. They assume that the patient has already reached their EMSN threshold and is therefore eligible to receive EMSN benefits.

Scenario
A consultation item has a:

• MBS Fee of $100;
• 85 per cent out-of-hospital rebate of $85; and
• 300 per cent EMSN benefit cap of $300.

Example 1
If the doctor charges $120 for the service, the patient will receive:

• 85 per cent out-of-hospital rebate of $85; and
• 80 per cent of their remaining out-of-pocket amount or $300, whichever is the lesser amount. In this example, their initial out-of-pocket cost is $35 (i.e. $120 - $85 = $35). Eighty percent of that out-of-pocket cost is $28 (i.e. 80% x $35 = $28). As such, they will receive an EMSN benefit of $28.
• This means that the patient will receive a total benefit of $113 (i.e. $85 + $28 = $113) from Medicare, and will have a final out-of-pocket $7 (i.e. $120 - $113 = $7).

Example 2
If the doctor charges $500 for the service the patient will receive:

• 85 per cent out-of-hospital rebate of $85; and
• 80 per cent of the remaining out-of-pocket amount or $300, whichever is the lesser amount. In this example, their initial out of pocket cost is $415 (i.e. $500 - $85 = $415). Eighty percent of that out-of-pocket cost is $332 (i.e. 80% x $415 = $332). This is higher than the EMSN cap for this item of $300.
• This means that the patient will receive the EMSN cap of $300 as this is the lower amount. The patient will receive a total benefit of $385 (i.e. $85 + $300 = $385) from Medicare, and will have a final out-of-pocket cost of $115 (i.e. $500 - $385 = $115).

The full list of MBS items is available online on this website. Use the search function on the website to find any Medicare item and its associated MBS fees and rebates. If an item has an EMSN benefit cap, it will appear in the item description.

Further information
For more information visit the Medicare website or contact Services Australia:

Medicare
GPO Box 9822
in your capital city

Phone: 132 011 (local call rate) 24 hours 7 days a week.
Further background on the EMSN is also available on the Department of Health and Aged Care’s website.