Changes to the Extended Medicare Safety Net - 1 January 2011

This fact sheet has been updated to reflect amended capping amounts of Extended Medicare Safety Net (EMSN) benefits.

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Last Updated - 12 July 2011.

PDF version of Changes to the Extended Medicare Safety Net Factsheet (PDF 143 KB)

What is the Extended Medicare Safety Net?

The EMSN provides an additional rebate for Australian families and singles who incur out of-pocket costs for out-of-hospital services. Out-of-hospital services include GP and specialist attendances. Once the relevant annual threshold of out-of-pocket costs has been met, Medicare will pay for 80% of any future out-of-pocket costs for out-of-hospital Medicare services for the remainder of the calendar year. However, as announced in the 2009 10 Budget, from 1 January 2010 there is an upper limit on the amount of benefit that can be paid under the EMSN for a small number of Medicare services.

In 2011, the annual EMSN threshold for concession cardholders, including the Pensioner Concession Card, Health Care Card and the Seniors Health Card and people who receive Family Tax Benefits (Part A) is $578.60. For all other singles and families the annual threshold is $1,157.50. These amounts are indexed by Consumer Price Index on 1 January each year.

What services are not eligible for the EMSN?

In-hospital services are not eligible for the EMSN. Where people receive their treatment in hospital as a private patient they are eligible for a Medicare rebate equal to 75% of the Medicare Schedule fee. If they hold Private Health Insurance (PHI), they may also receive a rebate from their PHI fund.

Many day surgery facilities are classified as hospitals in Australia. It is important that patients discuss with their doctor the likely out-of-pocket costs for their treatment, including any rebates paid through Medicare.

The EMSN provides an additional Medicare rebate for eligible services. It is not available for services for which a Medicare rebate is not paid and out-of-pocket costs for these services do not count towards the annual EMSN threshold.

What changed on 1 January 2010?

From 1 January 2010, an upper limit was placed on the amount of benefit that can be paid under the EMSN for a small number of Medicare services. The upper limit of the EMSN benefit is called the EMSN benefit cap.

What is EMSN benefit capping?

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.

Which Medicare services have an EMSN benefit cap?

All Medicare services that are currently eligible for EMSN benefits continue to be eligible. The only thing that has changed is that there is now a maximum limit on the amount of benefit that will be paid for some MBS items under the EMSN. The EMSN benefit is payable in addition to the standard Medicare benefit for that item.

The items that have an EMSN benefit cap are:

• All obstetrics services;
• Some pregnancy related ultrasounds;
• All Assisted Reproductive Technology (ART) services;
• One type of varicose vein surgery (MBS item 32500);
• One type of cataract surgery (MBS item 42702); and
• Hair transplantation for the treatment of hair loss as the result of disease or injury (MBS item 45560).

On 1 July 2011 four new services were introduced into the MBS with EMSN benefit caps. These services include:

• two services relating to the injection of poly-L-lactic acid for the treatment of severe facial lipoatrophy; and
• two services relating to the initiation of videoconference for selected obstetric and ART services.

In addition, on 1 July 2011 22 new items relating to pregnancy ultrasounds were introduced into the MBS with EMSN benefit caps. These items are not new services. Rather, these items ‘mirror’ the existing pregnancy related ultrasound items, but have reduced benefit amounts as they are claimable for services provided using aged equipment. Capping of these items falls under the Capital Sensitivity Budget measure, announced in the 2009-10 Federal Budget. Further information on this measure can be found on the Department of Health and Ageing website at www.health.gov.au.

A list of the affected MBS items and the levels of the EMSN benefit caps appears later in this document.

Why were those Medicare items chosen?

The Medicare items that were capped on 1 January 2010 following a 2009-10 Budget measure were identified in the Extended Medicare Safety Net Review Report 2009 (the Review report) as areas of concern.

The Review report found that between 2003 and 2008, the fees charged by obstetricians for
in-hospital services reduced whilst the fees charged for out-of-hospital services increased significantly.

Similarly, the Review report found that the fees charged for ART services fell by 9% for in-hospital services, whilst the fees charged for out-of-hospital services increased by 62%.
This indicated that some doctors were structuring their billing to take advantage of the EMSN, as the fees charged for out-of-hospital services increased far in excess of the fees charged for in-hospital services.

The Review report also found that for some Medicare services with high out-of-pocket costs, such as varicose vein treatment, one type of cataract surgery and some ART services, for every EMSN dollar, 78 cents was spent on meeting doctors’ higher fees, rather than reducing patients’ out-of-pocket costs.

The EMSN benefit is intended to be a patient benefit. It is not intended to be a mechanism for doctors to increase their fees.

The Medicare item for hair transplantation for the treatment of alopecia was identified in the Review report as one of the top items for EMSN spend per service. This was confirmed by Medicare data that showed that in some cases, the fee charged for the Medicare item for hair transplantation was in excess of $10,000.

The Extended Medicare Safety Net Review Report can be found at http://www.health.gov.au/internet/main/publishing.nsf/Content/Review_+Extended_Medicare_Safety_Net

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Why were caps placed on items introduced on 1 July 2011?

The EMSN benefit caps placed on the pregnancy ultrasound items introduced through the capital sensitivity measure and the caps placed on the two items relating to obstetric and ART consultations via videoconference were necessary to maintain consistency with the existing EMSN benefit caps.
If these items were not capped, there would have been an incentive for practitioners to shift a higher proportion of their fees onto these items.
Capping of the two items relating to the injection of poly-L-lactic acid for the treatment of severe facial lipoatrophy was based on the recommendation of the Medical Services Advisory Committee (MSAC).

How do the EMSN benefit caps work in practice?

The EMSN benefit cap is applied at the item level. This means that the same level of EMSN benefit cap applies to all claims for that item, regardless of the fee charged by the doctor.

All patients who have reached their EMSN threshold are eligible to receive an EMSN benefit up to the amount of the EMSN benefit cap each time that they claim for a capped service.

For a capped item the method for determining the EMSN benefit is the same, that is 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).

The following example illustrates the effect of capping EMSN benefits. The scenario assumes that the patient has already reached the EMSN threshold and is therefore eligible for EMSN benefits.

Item 16500, an antenatal attendance has a MBS Schedule Fee of $45.35 and MBS rebate of $38.55 and a $31.40 EMSN cap for services provided after 1 January 2011. Under the uncapped arrangements if the doctor charges $83.55 for this service, a patient can receive an EMSN benefit of up to $40.00 (80% of their out-of-pocket cost in addition to the $38.55 rebate. This is $74.55 in total). With an EMSN cap set at $31.40, then the person would only receive an EMSN benefit of up to $31.40 ($69.95 in total including the MBS rebate). For a person charged $73.55, the EMSN benefit would be $28.00, as this is equal to 80% of their out-of-pocket costs for the claim ($66.55 in total including the MBS rebate). There is no impact on this patient as the EMSN benefit they are entitled to ($28.00) is less than the EMSN benefit cap ($31.40). The EMSN benefit caps are only relevant for out-of-hospital services, as EMSN benefits are only paid for out-of-hospital services. The introduction of EMSN benefit caps does not impact on the amount that patients receive through their private health insurance.

How am I affected by capping?

Most people are not affected by capping. If you have a capped service you still receive the standard Medicare rebate for the service. You are still eligible to receive EMSN benefits for all out-of-hospital Medicare services once you reach the EMSN threshold. The only thing that has changed is that there is a maximum limit placed on the amount that you get back through the EMSN for selected items from 1 January 2010.

For all other Medicare out-of-hospital services, you continue to receive 80% of your total out-of-pocket cost.

Are the levels of the EMSN benefits caps indexed?

The EMSN benefit caps are indexed by Consumer Price Index (CPI) on 1 January each year. On 1 January 2011, the EMSN benefit caps will be increased by 3.1% (the June quarter annual CPI).

The effect of indexation on patient benefits

The MBS Schedule Fees and rebates for most MBS items are indexed on 1 November each year. The level of the EMSN benefit cap is indexed on 1 January each year. This means that the maximum amount of Medicare benefits payable increases twice each year, once in January and once in November.

The tables below provide an illustration of the impact of indexation of MBS rebates and EMSN benefit caps for one MBS item, 32500 for varicose vein treatment using the injection of a sclerosant.
Services provided 1 January 2010 to 31 October 2010

MBS Schedule Fee at 1 January 2010	A: MBS rebate at 1 January 2010*	B: EMSN Cap from 1 Jan 2010	A +B: Maximum Medicare benefit payable per claim out-of-hospital
$103.80	$88.25	$111.65	$199.90

Services provided 1 November 2010 to 31 December 2010 – MBS Schedule Fees and rebates indexed

MBS Schedule Fee from 1 November 2010	A: MBS rebate from 1 November 2010*	B: EMSN Cap from 1 Jan 2010	A +B: Maximum Medicare benefit payable per claim out-of-hospital
$105.65	$89.85	$111.65	$201.50

Services provided from 1 January 2011 – EMSN benefit caps increased

MBS Schedule Fee from 1 November 2010	A: MBS rebate from 1 November 2010*	B: EMSN Cap from 1 Jan 2011	A +B: Maximum Medicare benefit payable per claim out-of-hospital
$105.65	$89.85	$115.15	$205.00

*Rebate for out-of-hospital services.

Actual rebate payable depends on the amount of out-of-pocket cost that a patient needs to reach the EMSN threshold and the fee charged by the doctor.

What do patients and doctors need to do?

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

Will there be more EMSN benefit caps placed on Medicare services in the future?

At present, the EMSN benefit caps apply to the Medicare items listed in this fact sheet, including items for services provided by eligible midwives introduced on 1 November 2010.

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CAPPED ITEMS

Apart from obstetrics and some pregnancy ultrasounds, services provided by eligible midwives and ART services, EMSN benefit caps apply to only three MBS items, as outlined below.

Item number	Description	From 1 November 2010 ($)		EMSN benefit cap ($)		Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Schedule Fee	A: MBS rebate*	B: 2011 calendar year		From 1 January 2011 (A+B)
14201	Injection of poly-L-lactic acid for the treatment of severe facial lipoatrophy (initial session)	227.90 **	193.75 **	34.15 **		227.90 **
14202	Injection of poly-L-lactic acid for the treatment of severe facial lipoatrophy (subsequent sessions)	115.35 **	98.05 **	17.30 **		115.35 **
32500	Varicose vein treatment via injection of sclerosant	105.65	89.85	115.15		205.00
42702	Cataract surgery	731.80	660.60	104.65		765.25
45560	Hair Transplantation	455.70	387.35	157.00		544.35

# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient needs to reach the EMSN threshold and the fee charged by the doctor.
* Maximum benefit payable for out-of-hospital service. The majority of cataract surgeries are performed on an in-hospital basis.
** Item introduced on 1 July 2011

ASSISTED REPRODUCTIVE TECHNOLOGY

What is the new item structure for Assisted Reproductive Technologies?

As announced at the 2009-10 Budget, the Medicare items for Assisted Reproductive Technology (ART) services, including In-Vitro Fertilisation (IVF), have been restructured in negotiation with the ART profession and patient group ACCESS. This structure better reflects current clinical practice and benefits patients as the base MBS rebates have been increased for a typical treatment cycle. In some cases, patients receive increased base MBS rebates which are significantly higher across a typical treatment cycle. The new structure introduced on 1 January 2010 shows that the patients that are charged $6,000 for Medicare eligible services associated with a typical treatment cycle will not be worse off under these changes. More information about the new ART structure is provided below.

Will there be limits on access to ART services- such as limits on the number of cycles or age restrictions?

There is no restriction on the number of cycles that patients can have under Medicare. Nor is there any age restriction placed on ART services for Medicare purposes.

What are the current MBS rebates and caps for ART services?

The following table provides information on the MBS Schedule fees and rebates in place from 1 November 2010. From 1 January 2010 the EMSN benefit caps increase (from column B to column C). This increases the maximum Medicare benefit payable per claim. Patients may not receive this maximum if they have not already qualified for the EMSN in the relevant calendar year.

What are the EMSN benefit caps for the ART items?

Item number	Description	From 1 November 2010 ($)		EMSN benefit cap ($)		Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Schedule Fee	A: MBS rebate	B: 2011 calendar year		From 1 January 2011 (A+B)
13200	ART services - superovulated treatment cycle proceeding to oocyte retrieval – initial cycle in a calendar year	2,992.90	2,921.70	1598.05		4,519.75
13201	ART services- superovulated treatment cycle proceeding to oocyte retrieval – subsequent cycle in a calendar year	2,799.50	2,728.30	2319.75		5,048.05
13202	ART services – superovulated cycles that is cancelled prior to oocyte retrieval	447.90	380.75	61.90		442.65
13203	Ovulation monitoring services for artificial insemination	468.30	398.10	103.10		501.20
13206	ART services - natural treatment cycle or treatment cycle where oocyte growth & development is induced using oral medication only	447.90	380.75	61.90		442.65
13209	Planning and management of an ART treatment cycle	81.45	69.25	10.35		79.60
13210	Initiation of a professional attendance via videoconference, where that service relates to item 13209	derived fee **		5.00 **
13212	Oocyte retrieval	341.05	289.90	67.05		356.95
13215	Transfer of embryos to the female reproductive system	106.90	90.90	46.40		137.30
13218	Preparation of frozen or donated embryos	763.50	692.30	670.15		1,362.45
13221	Preparation of semen for artificial insemination	48.85	41.55	20.65		62.20
13251	Intracytoplasmic sperm injection	402.10	341.80	103.10		444.90

* For out-of-hospital services the rebate is 85 per cent of the MBS Fee. For in-hospital services the rebate is 75 per cent of the MBS Fee and no benefits are available through the EMSN.
**Item introduced on 1 July 2011.
# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient requires to reach the EMSN threshold and the fee charged by the doctor. There is no guarantee that a patient will actually receive this level of rebate.
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OBSTETRIC SERVICES

What action is being taken to minimise the impact on patients?

The 2009-10 Budget also included funding of $120.5 million for a maternity services reform package to provide greater choice for women, while maintaining Australia’s strong record of safe, high quality maternity services.

The Maternity Services package includes:

• MBS and Pharmaceutical Benefits Scheme (PBS) benefits for services provided by eligible midwives, to provide greater access to maternity care provided by midwives working in collaboration with doctors – expanding choice for women.
• A Government-supported professional indemnity insurance scheme for eligible midwives.
• More services for rural and remote communities, where the state of maternity services is poor, through an expansion of the successful Medical Specialist Outreach Assistance Program (MSOAP).
• Extra scholarships for GPs and midwives to expand the maternity workforce, particularly in rural and remote Australia.
• A new 24 hour, seven days a week telephone helpline and information service to provide women, their partners and families with greater access to maternity information and support before and after birth.

The package will be implemented progressively with new Medicare arrangements for midwives beginning from 1 November 2010.

The Medicare rebates for 15 obstetrics items were increased at a cost of $157.6 million over four years. This increase is of particular benefit for those women that do not qualify for EMSN benefits. The increased Medicare rebates commenced from 1 January 2010.

Which Obstetrics services had an increase in the rebate?

The Medicare rebates for 15 obstetrics services were increased from 1 January 2010, including:

• The planning and management of pregnancy;
• All Medicare items for the management of labour and delivery;
• Standard antenatal attendances; and
• Antenatal attendances where the patient is in hospital for treatment of particular conditions such as premature labour.

Over a standard course of maternity care, the base MBS rebates were increased by about $300 per patient. This means that all patients will now receive a higher rebate before they even qualify for the EMSN.

Information on the current items can be found in the table which sets out the EMSN benefit caps for the obstetric items.

What are the new attendance items 16401 and 16404?

Two new items for consultations relating to pregnancy, 16401 and 16404, were introduced into the obstetrics section of the MBS. These items have the same fee as the specialist attendance items 104 and 105. As is the current arrangement for items 104 and 105, these items will be restricted to specialists. These new items are also subject to EMSN benefit caps.

From 1 January 2010, these items should be claimed for any attendance relating to pregnancy, including any initial attendance with the obstetrician for discussion of the pregnancy or any postnatal care provided to the patient subsequent to the expiration of the normal aftercare period. It is still intended that item 16500 will be claimed for routine antenatal attendances.

Practitioners are required to bill the Medicare item that best describes the service that they provide. Additionally, under the Health Insurance Act 1973, the amount that is specified on the account must be the amount charged for the service that is specified. This means that any component for other goods or services that are not part of the MBS item that is being billed must not be included in the fee for that item. For example, the fee charged for a service cannot be loaded onto the fee for another service.

What are the EMSN benefit caps for the obstetric items?

Item number	Description	From 1 November 2010 ($)		EMSN benefit cap ($)		Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Schedule Fee	A: MBS rebate *	B: 2011 calendar year		From 1 January 2011 (A+B)
16399	Initiation of a professional attendance via videoconference, where that service relates to item 16401, 16404, 16406, 16500, 16590 or 16591	derived fee **		22.95 **
16400	Antenatal attendance by a nurse or midwife on the behalf of a medical practitioner	26.25	22.35	10.50		32.85
16401	Initial specialist attendance by a practitioner in the practice of obstetrics	82.30	70.00	52.35		122.35
16404	Subsequent specialist attendance by a practitioner in the practice of obstetrics	41.35	35.15	31.40		66.55

* For out-of-hospital services the rebate is 85 per cent of the MBS Fee. For in-hospital services the rebate is 75 per cent of the MBS Fee and no benefits are available through the EMSN.
**Item introduced on 1 July 2011.
# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient requires to reach the EMSN threshold and the fee charged by the doctor. There is no guarantee that a patient will actually receive this level of rebate.

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What are the EMSN benefit caps for the obstetric items (continued)?

Item number	Description	From 1 November 2010 ($)		EMSN benefit cap ($)		Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Schedule Fee	A: MBS rebate ^	B: 2010 calendar year C: 2011 calendar year		1 November 2010 to 31 December 2010 (A+B) From 1 January 2011 (A+C)
16406	32 to 36 week obstetric visit - Antenatal professional attendance, as part of a single course of treatment, at 32-36 weeks of the patient's pregnancy when the patient is referred by a participating midwife. Payable only once for a pregnancy.	128.85	109.55	103.10		212.65
16500	Antenatal attendance	45.35	38.55	31.40		69.95
16501	External Cephalic Version for Breech Presentation, After 36 Weeks	135.25	115.00	62.80		177.80
16502	Attendance for treatment of Polyhydramnios, Unstable Lie, Multiple Pregnancy, Pregnancy Complicated by Diabetes or Anaemia, Threatened Premature Labour Treated by Bed Rest Only or Oral Medication	45.35	75% 34.05 85% 38.55	20.95		Usually provided in hospital*
16504	Attendance for the treatment of Habitual Miscarriage by Injection of Hormones Each Injection Up to a Maximum of 12 Injections	45.35	75% 34.05 85% 38.55	20.95		59.50
16505	Attendance for threatened Abortion, Threatened Miscarriage or Hyperemesis Gravidarum	45.35	75% 34.05 85% 38.55	20.95		Usually provided in hospital*

* For out-of-hospital services the rebate is 85 per cent of the MBS Fee. For in-hospital services the rebate is 75 per cent of the MBS Fee and no benefits are available through the EMSN.
# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient requires to reach the EMSN threshold and the fee charged by the doctor. There is no guarantee that a patient will actually receive this level of rebate.
^ For items where the service is usually provided in-hospital, the rebates have been given for the in-hospital 75% rate and the out-of-hospital 85% benefit rate.

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What are the EMSN benefit caps for the obstetric items (continued)?

Item number	Description	From 1 November 2010 ($)		EMSN benefit cap ($)	Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Schedule Fee	A: MBS rebate^	B: 2011 calendar year	From 1 January 2011 (A+B)
16508	Attendance for Pregnancy Complicated by Acute Intercurrent Infection, Intrauterine Growth Retardation, Threatened Premature Labour With Ruptured Membranes or Threatened Premature Labour Treated by Intravenous Therapy	45.35	75% 34.05 85% 38.55	20.95	Usually provided in hospital*
16509	Attendance for the treatment of Preeclampsia, Eclampsia or Antepartum Haemorrhage	45.35	75% 34.05 85% 38.55	20.95	Usually provided in hospital*
16511	Purse String Ligation of Cervix	211.60	75% 158.70 85% 179.90	104.65	Usually provided in hospital*
16512	Removal of Purse String Ligature of Cervix	61.10	75% 45.85 85% 51.95	31.40	Usually provided in hospital*
16514	Antenatal Cardiotocography in the Management of High Risk Pregnancy	35.25	30.00	15.75	45.75
16515	Management of Vaginal Delivery As An Independent Procedure Where the Patient's Care Has Been Transferred by Another Medical Practitioner for Management of the Delivery	433.60	75% 325.20 85% 368.60	167.45	Usually provided in hospital*
16518	Management of Labour, Incomplete, Where the Patient's Care Has Been Transferred to Another Medical Practitioner for Completion of the Delivery	433.60	75% 325.20 85% 368.60	167.45	Usually provided in hospital*

* For out-of-hospital services the rebate is 85 per cent of the MBS Fee. For in-hospital services the rebate is 75 per cent of the MBS Fee and no benefits are available through the EMSN.
# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient requires to reach the EMSN threshold and the fee charged by the doctor. There is no guarantee that a patient will actually receive this level of rebate.
^ For items where the service is usually provided in-hospital, the rebates have been given for the in-hospital 75% rate and the out-of-hospital 85% benefit rate.

What are the EMSN benefit caps for the obstetric items (continued)?

Item number	Description	From 1 November 2010 ($)		EMSN benefit cap ($)	Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Schedule Fee	A: MBS rebate^	B: 2011 calendar year	From 1 January 2011 (A+B)
16519	Management of Labour and Delivery by Any Means (Including Caesarean Section) Including Post-partum Care for 5 Days	667.65	75% 500.75 85% 596.45	313.95	Usually provided in hospital*
16520	Caesarean Section and Post-operative Care for 7 Days Where the Patient's Care Has Been Transferred by Another Medical Practitioner	780.35	75% 585.30 85% 709.15	313.95	Usually provided in hospital*
16522	Management of complicated birth	1,567.60	75% 1,175.70 85% 1,496.40	418.60	Usually provided in hospital*
16525	Management of Second Trimester Labour, With or Without Induction, for Intrauterine Fetal Death, Gross Fetal Abnormality or Life Threatening Maternal Disease	369.80	75% 277.35 85% 314.35	146.55	Usually provided in hospital*
16527	Management of Vaginal Delivery, if the patient's care has been transferred by a participating midwife for management of the delivery, including all attendances related to the delivery. Payable once only for a pregnancy.	433.60	75% 325.20 85% 368.60	167.45	Usually provided in hospital*
16528	CAESAREAN SECTION and post-operative care for 7 days, if the patient's care has been transferred by a participating midwife for management of the birth. Payable once only for a pregnancy.	780.35	75% 585.30 85% 709.15	313.95	Usually provided in hospital*

* For out-of-hospital services the rebate is 85 per cent of the MBS Fee. For in-hospital services the rebate is 75 per cent of the MBS Fee and no benefits are available through the EMSN.
# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient requires to reach the EMSN threshold and the fee charged by the doctor. There is no guarantee that a patient will actually receive this level of rebate.
^ For items where the service is usually provided in-hospital, the rebates have been given for the in-hospital 75% rate and the out-of-hospital 85% benefit rate.
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What are the EMSN benefit caps for the obstetric items (continued)?

Item number	Description	From 1 November 2010 ($)		EMSN benefit cap ($)	Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Schedule Fee	A: MBS rebate^	B: 2011 calendar year	From 1 January 2011 (A+B)
16564	Evacuation of Retained Products of Conception (Placenta, Membranes or Mole) As a Complication of Confinement, With or Without Curettage of the Uterus	209.75	75% 157.35 85% 178.30	209.30	Usually provided in hospital*
16567	Management of Postpartum Haemorrhage by Special Measures Such As Packing of Uterus	306.70	75% 230.05 85% 260.70	209.30	Usually provided in hospital*
16570	Vaginal Correction of Acute Inversion of the Uterus	400.30	75% 300.25 85% 340.30	209.30	Usually provided in hospital*
16571	Repair of Extensive Laceration or Lacerations of the Cervix	306.70	75% 230.05 85% 260.70	209.30	Usually provided in hospital*
16573	Repair of Third Degree Tear, Involving Anal Sphincter Muscles and Rectal Mucosa	249.95	75% 187.50 85% 212.50	209.30	Usually provided in hospital*
16590	Planning and Management of a Pregnancy That Has Progressed Beyond 20 Weeks.	311.80	265.05	209.30	474.35
16591	Planning and Management of a Pregnancy where the care of the patient will be transferred to another medical practitioner for the labour and delivery	137.25	116.70	104.65	221.35
16600	Amniocentesis	61.10	51.95	31.40	83.35
16603	Chorionic Villus Sampling	117.25	99.70	62.80	162.50
16606	Fetal Blood Sampling From Umbilical Cord or Fetus	234.00	198.90	125.60	324.50

* For out-of-hospital services the rebate is 85 per cent of the MBS Fee. For in-hospital services the rebate is 75 per cent of the MBS Fee and no benefits are available through the EMSN.
# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient requires to reach the EMSN threshold and the fee charged by the doctor. There is no guarantee that a patient will actually receive this level of rebate.
^ For items where the service is usually provided in-hospital, the rebates have been given for the in-hospital 75% rate and the out-of-hospital 85% benefit rate.
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What are the EMSN benefit caps for the obstetric items (continued)?

Item number	Description	From 1 November 2010 ($)		EMSN benefit cap ($)	Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Schedule Fee	A: MBS rebate	B: 2011 calendar year	From 1 January 2011 (A+B)
16609	Fetal Intravascular Blood Transfusion, Using Blood Already Collected, Including Neuromuscular Blockade, Amniocentesis and Fetal Blood Sampling.	477.20	406.00	240.70	646.70
16618	Amniocentesis, Therapeutic	199.95	170.00	99.45	269.45
16624	Drainage of Fetal Fluid Filled Cavity	287.75	244.60	136.05	380.65
16627	Feto-amniotic Shunt, Insertion of, Into Fetal Fluid Filled Cavity, Including Neuromuscular Blockade and Amniocentesis	585.90	514.70	293.05	807.75
16633	Procedure On Multiple Pregnancies Relating to Items 16606, 16609, 16612, 16615 and 16627	derived fee		219.80
16636	Procedure On Multiple Pregnancies Relating to Items 16600, 16603, 16618, 16621 and 16624	derived fee		83.75

* For out-of-hospital services the rebate is 85 per cent of the MBS Fee. For in-hospital services the rebate is 75 per cent of the MBS Fee and no benefits are available through the EMSN.
# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient requires to reach the EMSN threshold and the fee charged by the doctor. There is no guarantee that a patient will actually receive this level of rebate.

Why are EMSN benefit caps applied on labour and delivery items when these services are usually provided in-hospital?

EMSN benefit caps are only relevant for out-of-hospital services, as EMSN benefits are only paid for out-of-hospital services. Whilst the majority of services for items which cover labour and delivery are provided in-hospital, there are a small proportion of patients that receive these services out-of-hospital.

EMSN benefit caps are also applied to items in recognition that some patients and doctors choose to have these services out-of-hospital and to ensure consistency in the application of EMSN benefit caps across MBS obstetrics services.
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What are the EMSN benefit caps on pregnancy ultrasounds?

Description	Item number	From 1 November 2010 ($)		EMSN benefit cap ($)	Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Fee	A: MBS rebate*	B: 2011 calendar year	From 1 January 2011 (A+B)
Pregnancy related scan - less than 12 weeks referred patient	55700	60.00	51.00	31.40	82.40
	55701^	30.00	25.50	15.70	41.20
Pregnancy related scan - less than 12 weeks non referred patient	55703	35.00	29.75	15.75	45.50
	55702^	17.50	14.90	7.90	22.80
Pregnancy related scan - 12 to 16 weeks referred patient	55704	70.00	59.50	36.65	96.15
	55710^	35.00	29.75	18.35	48.10
Pregnancy related scan - 12 to 16 weeks non referred patient	55705	35.00	29.75	15.75	45.50
	55711^	17.50	14.90	7.90	22.80
Pregnancy related scan - 17 to 22 weeks referred patient	55706	100.00	85.00	52.35	137.35
	55713^	50.00	42.50	26.20	68.70
Pregnancy related scan - rump length of 45 to 84mm referred patient	55707	70.00	59.50	36.65	96.15
	55714^	35.00	29.75	18.35	48.10
Pregnancy related scan - rump length of 45 to 84mm non referred patient	55708	35.00	29.75	15.75	45.50
	55716^	17.50	14.90	7.90	22.80
Pregnancy related scan - 17 to 22 weeks non referred patient	55709	38.00	32.30	20.95	53.25
	55717^	19.00	16.15	10.50	26.65
Pregnancy related scan - 17 to 22 weeks referred patient by obstetrician	55712	115.00	97.75	62.80	160.55
	55719^	57.50	48.90	31.40	80.30
Pregnancy related scan - 17 to 22 weeks non referred patient, performed by obstetrician	55715	40.00	34.00	20.95	54.95
	55720^	20.00	17.00	10.50	27.50
Pregnancy related scan - after 22 weeks referred patient	55718	100.00	85.00	52.35	137.35
	55722^	50.00	42.50	26.20	68.70
Pregnancy related scan - after 22 weeks referred patient by obstetrician	55721	115.00	97.75	62.80	160.55
	55724^	57.50	48.90	31.40	80.30
Pregnancy related scan - after 22 weeks non referred patient	55723	38.00	32.30	20.95	53.25
	55726^	19.00	16.15	10.50	26.65
Pregnancy related scan - after 22 weeks non referred patient, performed by obstetrician	55725	40.00	34.00	20.95	54.95
	55727^	20.00	17.00	10.50	27.50

* For out-of-hospital services the rebate is 85 per cent of the MBS Fee. For in-hospital services the rebate is 75 per cent of the MBS Fee and no benefits are available through the EMSN.
# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient requires to reach the EMSN threshold and the fee charged by the doctor. There is no guarantee that a patient will actually receive this level of rebate.
^ Items introduced under the Capital Sensitivity measure announced in the 2009-10 Federal Budget and claimable from 1 July 2011 for services provided using aged equipment.
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What are the EMSN benefit caps on pregnancy ultrasounds (continued)?

Description	Item number	From 1 November 2010 ($)		EMSN benefit cap ($)	Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Fee	A: MBS rebate*	B: 2011 calendar year	From 1 January 2011 (A+B)
Duplex scanning after 24th week	55729	27.25	23.20	15.75	38.95
	55730^	13.65	11.65	7.90	19.55
Pregnancy related scan - 17 to 22 weeks non referred patient which identifies multiple pregnancy	55762	60.00	51.00	31.40	82.40
	55763^	30.00	25.50	15.70	41.20
Pregnancy related scan - 17 to 22 weeks referred patient which identifies multiple pregnancy, performed by obstetrician	55764	160.00	136.00	83.75	219.75
	55765^	80.00	68.00	41.90	109.90
Pregnancy related scan - 17 to 22 weeks non referred patient which identifies multiple pregnancy, performed by obstetrician	55766	65.00	55.25	31.40	86.65
	55767^	32.50	27.65	15.70	43.35
Pregnancy related scan - after 22 weeks referred patient which confirms multiple pregnancy	55768	150.00	127.50	78.55	206.05
	55769^	75.00	63.75	39.30	103.05
Pregnancy related scan - after 22 weeks non referred patient which confirms multiple pregnancy	55770	60.00	51.00	31.40	82.40
	55771^	30.00	25.50	15.70	41.20
Pregnancy related scan - after 22 weeks referred patient by obstetrician which confirms multiple pregnancy	55772	160.00	136.00	83.75	219.75
	55773^	80.00	68.00	41.90	109.90
Pregnancy related scan - after 22 weeks referred patient which confirms multiple pregnancy performed by obstetrician	55774	65.00	55.25	36.65	91.90
	55775^	32.50	27.65	18.35	46.00

* For out-of-hospital services the rebate is 85 per cent of the MBS Fee. For in-hospital services the rebate is 75 per cent of the MBS Fee and no benefits are available through the EMSN.
# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient requires to reach the EMSN threshold and the fee charged by the doctor. There is no guarantee that a patient will actually receive this level of rebate.
^ Items introduced under the Capital Sensitivity measure announced in the 2009-10 Federal Budget and claimable from 1 July 2011 for services provided using aged equipment.
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What are the EMSN benefit caps that apply to midwifery items?

Medicare benefits are payable for antenatal, intra-partum and postnatal services (provided in the 6 weeks post delivery), by eligible privately practicing midwives working in collaboration with a medical practitioner. These items were introduced on 1 November 2010. Participating midwives will also be able to request certain pathology and diagnostic imaging services for their patients and refer patients to obstetricians and paediatricians, as the clinical need arises.

Further information on these items is available on the MBS Online website or from Medicare Australia. The following midwifery items are subject to an EMSN benefit cap.

Item number	Description	From 1 November 2010 ($)		EMSN benefit cap ($)	Maximum Medicare benefit payable per claim out-of-hospital $ #
		MBS Fee	A: MBS rebate*	B: 2011 calendar year	From 1 January 2011 (A+B)
82100	Initial midwife attendance with a participating midwife - lasting at least 40 minutes	51.35	43.65	20.65	64.30
82105	Short antenatal attendance with a participating midwife - up to 40 minutes	31.10	26.45	15.50	41.95
82110	Long antenatal attendance with a participating midwife - lat least 40 minutes.	51.35	43.65	20.65	64.30
82115	Planning and management of pregnancy with a participating midwife that has progressed beyond 20 weeks lasting at least 90 minutes	306.90	260.90	51.55	312.45
82130	Short postnatal attendance with a participating midwife	51.35	43.65	15.50	59.15
82135	Long postnatal attendance with a participating midwife	75.55	64.25	20.65	84.90
82140	Six week postnatal attendance	51.35	43.65	15.50	59.15

* For out-of-hospital services the rebate is 85 per cent of the MBS Fee. For in-hospital services the rebate is 75 per cent of the MBS Fee and no benefits are available through the EMSN.
# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient requires to reach the EMSN threshold and the fee charged by the doctor. There is no guarantee that a patient will actually receive this level of rebate.
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