EMSN caps on selected procedural items and one ultrasound item from 1 November 2012

This fact sheet provides information on the EMSN benefit caps from 1 November 2012 announced in the 2012-13 Budget for selected procedural items and one ultrasound item.

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Extended Medicare Safety Net and EMSN capping Selected procedural items (from T8 in the MBS) and one ultrasound item

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Why were those Medicare items chosen?

The 38 procedural items and one ultrasound item that have an EMSN benefit cap from 1 November 2012 were identified in either the 2009 review of the EMSN, the 2011 review of EMSN capping (both reviews completed by the Centre for Health Economics Research and Evaluation (CHERE)), or by the department’s own analysis of Medicare data. The reports found that some specialist doctors felt fewer competitive constraints on their fees if they knew their patients would reach the EMSN threshold and get 80 per cent of their out of pocket costs reimbursed through the EMSN. The changes have been made to support the long term sustainability of the EMSN.

Both the 2009 review of the EMSN and the 2011 review of EMSN capping conducted by CHERE can be found on the Department of Health and Ageing website.

What will patients and doctors need to do to comply with the changes?

Doctors and patients are not required to do anything extra to comply with the changes. The EMSN benefit caps are stored in the Medicare Australia claiming systems and are applied by Medicare Australia at the time of processing the claim for payment.

What items have EMSN caps from 1 November 2012? (Excludes consultation items)

The EMSN benefit caps for the selected procedures and diagnostic item are equal to 80 per cent of the Medicare Benefits Schedule (MBS) fee for the item. The MBS procedures and diagnostic item that are capped from 1 November 2012 are available at the end of this fact sheet.

How will I be affected?

The majority of patients will not be affected. The caps will only apply in instances where the doctor’s fee results in a calculated EMSN benefit that is higher than the capped amount and where the patient has already reached the EMSN threshold.

Furthermore:
· There is no change in how people qualify for the EMSN;
· There is no impact on in-hospital services as they are not eligible for EMSN benefits; and
· There are no changes to the operation of the OMSN.

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

From 1 November 2012, item 45617, an upper eyelid reduction, has an MBS Fee of $235.05, an out of hospital MBS rebate of $199.80 and an EMSN benefit cap of $188.05. Example A: No impact to patients due to EMSN caps If the doctor charges $250.00 for the service, the patient’s out-of-pocket cost before EMSN benefits are paid is $50.20 (doctor’s fee minus the MBS rebate received). Assuming the patient has reached the relevant EMSN threshold, the EMSN benefit for this service is calculated to be $40.20 (80 per cent of the patient’s out-of-pocket cost). As the calculated EMSN benefit is below the EMSN benefit cap amount of $188.05 the patient will receive the full $40.20 in EMSN benefits. As a result, the total cost incurred by the patient is $10.00 and EMSN capping has no impact on the patient. Example B: Impact to patients due to EMSN caps If the doctor charges $500 for the service, the patient’s out-of-pocket cost before EMSN benefits are paid is $300.20 (doctor’s fee minus the MBS rebate received). Eighty per cent of the out-of-pocket cost would be equal to $240.20. This amount is higher than the EMSN benefit cap of $188.05, therefore, assuming the patient has reached the relevant EMSN threshold, the maximum EMSN benefit that the patient will receive is $188.05. The total MBS benefit for this service is calculated to be $387.85 (MBS rebate plus the EMSN benefit cap). As a result, the total cost incurred by the patient is $112.15. The effect of the doctor’s billing at this rate means that the EMSN benefit cap has impacted on the patient’s out of pocket cost.

Note: Medicare benefits are rounded up to the nearest 5 cents.

What are the EMSN benefit caps that will apply?

Item Number	Description of service	EMSN benefit cap (percentage of MBS fee up to $500)	EMSN cap ($)
11700	Electrocardiography, tracing and report.	80%	25.00
14100	Laser photocoagulation for the treatment of vascular lesions	80%	122.00
20142	Initiation of management of anaesthesia for lens surgery	80%	95.05
30071	Diagnostic biopsy of skin or mucous membrane	80%	41.80
31200	Removal of tumour, cyst, ulcer or scar by surgical excision	80%	27.20
31205	Removal of tumour, cyst, ulcer or scar by surgical excision	80%	76.40
31521	Total male mastectomy	80%	346.80
31527	Subcutaneous male mastectomy	80%	416.20
31560	Excision of accessory breast tissue	80%	277.40
32501	Varicose vein treatment	80%	87.85
32504	Varicose vein treatment	80%	214.15
32507	Varicose vein treatment	80%	426.90
34106	Ligation of artery or vein	80%	233.40
35533	Vulvoplasty or labioplasty	80%	279.90
37619	Reversal of male sterilisation - vasovasostomy or vasoepididymostomy	80%	221.30
42590	Canthoplasty – eyelid surgery	80%	270.70
42738	Injection of a therapeutic substance into the eye	80%	240.60
42739	Injection of a therapeutic substance into the eye	80%	240.60
42740	Injection of a therapeutic substance into the eye	80%	240.60
45003	Single stage local myocutaneous flap repair to 1 defect, simple and small	80%	481.35
45025	Carbon dioxide laser for scaring on face or neck	80%	141.90
45026	Carbon dioxide laser for scaring on face or neck – more than 1 area	80%	318.85
45200	Single stage local flap, where indicated, to repair 1 defect, simple or small,	80%	227.50
45203	Single stage local flap, where indicated, to repair 1 defect, complicated or large,	80%	324.85
45206	Single stage local flap, where indicated, to repair 1 defect, on eyelid, nose, lip, ear, neck, hand, thumb, finger or genitals	80%	306.85
45545	Reconstruction of nipple, areola or both	80%	498.05
45584	Liposuction	80%	505.40
45585	Liposuction	80%	505.40
45587	Meloplasty for correction of facial asymmetry due to soft tissue abnormality	80%	712.70
45614	Whole thickness reconstruction of eyelid other than by direct suture	80%	470.10
45617	Upper eyelid reduction	80%	188.05
45620	Lower eyelid reduction	80%	260.85
45623	Ptosis of eyelid (unilateral), correction of	80%	578.45
45624	Ptosis of eyelid, correction of, where previous ptosis surgery has been performed	80%	749.95
45632	Rhinoplasty, correction of lateral or alar cartilages	80%	409.60
45635	Rhinoplasty, correction of bony vault only	80%	470.10
45652	Rhinophyma, carbon dioxide laser or erbium laser excision-ablation of	80%	285.10
45659	Correction of lop ear, bat ear or similar deformity	80%	417.00
55054	Ultrasonic cross-sectional echography in conjunction with a surgical procedure using interventional techniques	80%	87.30

Note: Amounts are correct to 5 cents due to rounding.