EMSN caps on Psychiatry consultations 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 all Psychiatry consultation items.

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Extended Medicare Safety Net and EMSN capping Psychiatry items

(sub-group A.8 in the MBS)
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This fact sheet provides information on the EMSN benefit caps from 1 November 2012 that were announced in the 2012-13 Budget for all psychiatry consultation items. Separate fact sheets provide more information about the Extended Medicare Safety Net (EMSN) and the Original Medicare Safety Net (OMSN) and how EMSN benefit capping applies to other items.

Why are there EMSN caps on psychiatry items?

EMSN benefit caps have been introduced for all consultation and attendance items. The caps on all consultation items are equal to 300 per cent of the Medicare Benefits Schedule (MBS) fee to a maximum of $500.

The introduction of EMSN benefit caps for consultations responds to a number of issues raised in the independent review of the safety net arrangements in 2009 and the independent review of EMSN benefit capping in 2011. The changes have been made to support the long term sustainability of the EMSN.

What are the caps on psychiatry items?

The EMSN benefit cap is 300 per cent of the MBS Fee up to $500. That is, the EMSN benefit payable will be up to three times the MBS Fee, up to a maximum of $500.

How will I be affected?

The majority of patients will not be affected. The caps placed on consultations are set generously; therefore the caps will only apply in the small number of 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.
· 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 306, a consultation with a psychiatrist between 45 and 75 minutes, has an MBS Fee of $183.65, an out of hospital MBS rebate of $156.15 and an EMSN benefit cap of $500.00. Example A: No impact to patients due to EMSN caps If the psychiatrist charges $225 for the consultation, the patient’s out-of-pocket cost before EMSN benefits are paid is $68.85 (doctor’s fee minus the MBS rebate received). Assuming the patient has reached the relevant EMSN threshold, the EMSN benefit for this consultation is calculated to be $55.10 (80 per cent of the patient’s out of pocket cost). As the calculated EMSN benefit is below the EMSN benefit cap amount of $500.00 the patient will receive the full $55.10 in EMSN benefits. As a result, the total cost incurred by the patient is $13.75 and EMSN capping has no impact on the patient. Example B: Impact to patients due to EMSN caps If the psychiatrist charges $785 for the consultation, the patient’s out-of-pocket cost before EMSN benefits are paid is $628.85 (doctor’s fee minus the MBS rebate received). Eighty per cent of the out-of-pocket cost would be equal to $503.10. This amount is higher than the EMSN benefit cap of $500.00, therefore, assuming the patient has reached the relevant EMSN threshold, the maximum EMSN benefit that the patient will receive is $500.00. The total MBS benefit for this consultation is calculated to be $656.15 (MBS rebate plus the EMSN benefit cap). As a result, the total cost incurred by the patient is $128.85. The effect of the psychiatrist 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 to the psychiatry items?

Item Number	Brief description of service	EMSN benefit cap (percentage of MBS fee up to $500)	EMSN cap ($)
289	Development of a treatment and management plan for autism or other pervasive developmental disorder	300%	500.00
291	Assessment and management of a patient – more than 45 minutes duration	300%	500.00
293	Review of management plan – 30-54 minutes duration	300%	500.00
296	Initial consultation – more than 45 minutes duration	300%	500.00
297	Initial consultation – more than 45 minutes duration - hospital	300%	500.00
299	Initial consultation, home visit – more than 45 minutes duration	300%	500.00
300	Consultation of less than 15 minutes	300%	130.05
302	Consultation of between 15 and 30 minutes	300%	259.35
304	Consultation of between 30 and 45 minutes	300%	399.30
306	Consultation of between 45 and 75 minutes	300%	500.00
308	Consultation of more than 75 minutes	300%	500.00
310	Consultation of less than 15 minutes – where 50 services have been exceeded in a calendar year	300%	64.80
312	Consultation of between 15 and 30 minutes – where 50 services have been exceeded in a calendar year	300%	130.05
314	Consultation of between 30 and 45 minutes – where 50 services have been exceeded in a calendar year	300%	199.95
316	Consultation of between 45 and 75 minutes – where 50 services have been exceeded in a calendar year	300%	275.85
318	Consultation of more than 75 minutes – where 50 services have been exceeded in a calendar year	300%	319.80
319	Attendance of more than 45 minutes of a patient diagnosed with a severe personality disorder	300%	500.00
320	Consultation of less than 15 minutes at a hospital	300%	130.05
322	Consultation of more than 15 minutes to less than 30 minutes – hospital	300%	259.35
324	Consultation of more than 30 to 45 minutes – at a hospital	300%	399.30
326	Consultation of 45 to 75 minutes – at a hospital	300%	500.00
328	Consultation of more than 75 minutes – at a hospital.	300%	500.00
330	Attendance of lee than 15 minutes – where provided somewhere other than a consulting room or hospital	300%	238.65
332	Consultation of between 15 and 30 minutes – where provided somewhere other than a consulting room or hospital	300%	373.95
334	Consultation of between 30 and 45 minutes – where provided somewhere other than a consulting room or hospital	300%	500.00
336	Consultation of between 45 and 75 minutes – where provided somewhere other than a consulting room or hospital	300%	500.00
338	Consultation of more than 75 minutes – where provided somewhere other than a consulting room or hospital	300%	500.00
342	Group psychotherapy of more than 1 hour duration	300%	147.90
344	Group psychotherapy of more than 1 hour duration – involving a family group of 3 patients	300%	196.35
346	Group psychotherapy of more than 1 hour duration – involving a family group of 2 patients	300%	290.40
348	Consultation of between 20 and 45 minutes – where someone other than the patient is being interviewed	300%	380.25
350	Consultation of more than 45 minutes – where someone other than the patient is being interviewed	300%	500.00
352	Consultation of not more than 20 minutes – where someone other than the patient is being interviewed, over a course of continuing management of a patient	300%	380.25
353	Telepsychiatry of less than 15 minutes duration	300%	171.60
355	Telepsychiatry 15 minutes to 30 minutes	300%	343.35
356	Telepsychiatry 30 to 45 minutes	300%	500.00
357	Telepsychiatry 45 to 75 minutes	300%	500.00
358	Telepsychiatry more than 75minutes	300%	500.00
359	Telepsychiatry review 30 to 45 minutes	300%	500.00
361	Telepsychiatry – initial consultation less than 45 minutes	300%	500.00
364	Follow up to Telepsychiatry – less than 15 minutes	300%	130.05
366	Face to face Telepsychiatry follow up 15 minutes to 30 minutes	300%	259.35
367	Face to face Telepsychiatry follow up 30 minutes to 45 minutes	300%	399.30
369	Face to face Telepsychiatry follow up 45 minutes to 75 minutes	300%	500.00
370	Face to face Telepsychiatry follow up more than 75 minutes	300%	500.00

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