Out-of-hospital services include GP and specialist attendances, as well as many pathology and diagnostic imaging services. Once the relevant annual threshold has been met, Medicare will pay for 80 per cent of any future out-of-pocket costs for Medicare eligible out-of-hospital services for the remainder of the calendar year, except for a small number of services where an upper limit or ‘EMSN benefit cap’ applies.
There are two thresholds for the EMSN. These thresholds are indexed by the Consumer Price Index (CPI) on 1 January each year.
The 2013 annual EMSN thresholds are:
- $610.70 for Commonwealth concession cardholders, including those with a Pensioner Concession Card, a Health Care Card or a Commonwealth Seniors Card, and people who receive Family Tax Benefit (Part A); and
- $1,221.90 for all other singles and families.
- $624.10 for Commonwealth concession cardholders, including those with a Pensioner Concession Card, a Health Care Card or a Commonwealth Seniors Card, and people who receive Family Tax Benefit (Part A); and
- $1,248.70 for all other singles and families.
Further information relating to the OMSN can be found in the Links section below.
EMSN CappingEMSN caps apply to more than 500 MBS items. The items capped include:
- - All consultations;
- Obstetrics and assisted reproductive technology(ART) services; and
- Some surgical procedures.
On 1 November 2012, EMSN caps were placed on all consultation items, one ultrasound item and 38 other procedural items. The changes have been made to support the long term sustainability of the EMSN.
The EMSN benefit for a capped item is calculated as 80% of the patient’s out-of-pocket cost once the patient has reached the EMSN threshold. If this amount is greater than the EMSN benefit cap, the patient receives the EMSN benefit cap amount. If the calculated benefit is less than the EMSN benefit cap, the patient receives the calculated benefit (which is equal to 80% of the out-of-pocket costs for the claim).
Further information on EMSN capping, including the full list of capped items can be found in the Links section below.
Review of EMSN CappingIn mid 2011, the then Minister for Health and Ageing, the Hon Nicola Roxon tabled the ‘Review of Capping Arrangements Report 2011’ in both Houses of Parliament. The capping report is an independent review undertaken by the Centre for Health Economics Research and Evaluation (CHERE) who were engaged by the department to analyse:
- the operation of capping EMSN benefits;
- the extent to which the introduction of the EMSN benefits caps has made the EMSN more sustainable into the future; and
- any changes to fees charged, services provided and patients out of pocket costs for the capped items since the introduction of the EMSN benefits caps.
- Further information on the OMSN and the EMSN, including threshold eligibility and how to register as a family can be found on the Medicare Australia website
- Family Tax Benefit (Part A) and Commonwealth concession cards information and eligibility requirements can found on the Centrelink website
- Information on EMSN capping including the full list of capped items and examples of how EMSN benefits are calculated for a capped item can be found under the ‘fact sheets’ section at MBS Online
- Senate Community Affairs Committee Inquiry into the Health Insurance (Extended Medicare Safety Net) Bill 2009 can be found on the Parliament of Australia’s website
- Extended Medicare Safety Net Review Report 2009 completed by the Centre for Health Economics Research and Evaluation and tabled in Parliament on 12 May 2009 can be found on the Department of Health website
- Review of Capping Arrangements Report 2011 completed by the Centre for Health Economics Research and Evaluation and tabled in Parliament can be found on the Department of Health website.