EMSN capping from 1 November 2012 for MBS Items for injection of a therapeutic substance into the eye

This fact sheet provides information on the Extended Medicare Safety Net (EMSN) benefit caps from 1 November 2012 announced in the 2012-13 Budget.

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Extended Medicare Safety Net and EMSN capping Injection of a therapeutic substance into the eye (MBS items 42738, 42739 and 42740)

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This fact sheet provides information on the Extended Medicare Safety Net (EMSN) benefit caps from 1 November 2012, announced in the 2012-13 Budget, for the injection of a therapeutic substance into the eye (MBS items 42738, 42739 and 42740).

Medicare Benefits Schedule (MBS) item 42738 is commonly used for the injection associated with the treatment of age related macular degeneration. MBS items 42739 and 42740 are usually provided in hospital, where EMSN benefits are not payable. However, EMSN benefits for these items are also being capped for consistency.

Outline of the changes

Most patients will not be affected by the changes. There are no changes to how people qualify for the EMSN.

All that has changed is that there will be a limit on how much the Government pays for some items.

In 2011 EMSN expenditure for item 42740 was $12.8 million, 52% more than in 2010.

The changes have been made to support the long term sustainability of the EMSN.

How will patients be affected?

The changes from 1 November 2012 mean that the maximum amount patients can receive in additional Medicare benefits through the EMSN is $240.60 each time their doctor charges them for an MBS eye injection item 42738, 42739 or 42740.

This EMSN benefit cap is on top of the Medicare rebate of $255.65. This means that Medicare may pay up to $496.25 for the item, assuming the patient has reached the relevant EMSN threshold.

No patient who is charged less than $556.40 for an eye injection item will be affected by the change.

This change will not affect people who are admitted to hospital or a day surgery facility for their treatment as EMSN benefits are not paid for hospital services.

In 2011, the average EMSN benefit paid per eye injection service was $87. The EMSN benefit cap will be 2.7 times this amount.

What Medicare benefit will I receive under the changes?

The EMSN benefit cap will be equal to 80 per cent of the MBS Schedule Fee for all capped procedures. The following table, based on 1 November 2012 MBS fees, shows the EMSN cap amount, Medicare rebate and the minimum fee a patient must be charged in order to be affected by the EMSN benefit cap:

Item Number	Brief Description of service	MBS Schedule Fee ($) (A)	MBS Rebate for out-of-hospital services (B)	EMSN benefit cap percentage (C)	A x C EMSN Cap ($) (D)	B + D: Maximum Medicare benefit payable per claim out-of-hospital ($) (E)	Minimum fee for a patient to be affected by the changes (assuming they had already qualified for the EMSN) ($)
42738	Injection of therapeutic substances, or the removal of aqueous or vitreous humours for diagnostic or therapeutic purposes, 1 or more of, as an independent procedure.	300.75	255.65	80%	240.60	496.25	556.40*
42739	injection of therapeutic substances, or the removal of aqueous or vitreous humours for diagnostic or therapeutic purposes, 1 or more of, as an independent procedure, for a patient requiring anaesthetic services.	300.75	255.65	80%	240.60	496.25	556.40*
42740	Injection of therapeutic substances, or the removal of vitreous humour for diagnostic purposes, 1 or more of, as a procedure associated with other intraocular surgery.	300.75	255.65	80%	240.60	496.25	556.40*

*or up to $601.50 for someone who had also qualified for the OMSN. OMSN benefits remain unchanged.

How do I calculate my Medicare benefit?

When calculating whether or not you will be affected by the changes it is important to check what fee you are actually being charged for eye injection services and in particular item 42738. The total fee charged by the doctor for your injection and consultation may include other MBS items.

You may wish to discuss the impact of the changes on you with your doctor. Your doctor is obliged to provide you with full information about fees and other related medical costs. Doctors are free to set their own fees but are encouraged to take into account the financial circumstances of their patients.

Why are EMSN benefit caps being introduced for treatment of macular degeneration?

Capping of these eye injection items will address excessive fee charging by a very small number of doctors and will reduce Medicare expenditure.

What about caps on other items?

The EMSN benefit cap is 300 per cent of the MBS Schedule Fee for most attendance and consultation items. That is, the EMSN benefit payable will be up to three times the MBS Schedule Fee, up to a maximum of $500. Information regarding these changes can be found in a separate fact sheet on MBS Online.