About Medicare safety nets
Medicare safety nets support people who have high out-of-pocket medical costs for services provided out-of-hospital. The safety nets do not apply to services that are not listed on the Medicare Benefits Schedule (MBS) or to MBS services that are delivered in hospital.
Once your out-of-pocket medical costs reach a certain amount, Medicare gives you a higher amount back for the rest of the year. The increased benefits apply to either your:
- ‘gap expenses’ – the difference between the Medicare benefit you get and the schedule fee
- ‘out-of-pocket expenses’ – the difference between the Medicare benefit you get and what your health practitioner charges.
Anyone enrolled in Medicare is eligible for these safety nets. Services Australia keeps a tally of your MBS service expenses – you can see where you’re up to any time.
Read more about the Medicare safety nets.
Greatest Permissible Gap (GPG)
The GPG is defined in Section 10(3) of the national Health Insurance Act 1973 and requires that the difference between the MBS fee for an item and the 85% Medicare benefit must not be greater than a specified amount. In other words the GPG is a rule that sets a maximum gap dollar amount.
The GPG amount is indexed annually on 1 November in line with the consumer price index (June quarter).
From 1 November 2023, the GPG is set at $98.70, which means that all out-of-hospital Medicare services which have an MBS fee of $658.35 or more will attract a benefit that is greater than 85% of the MBS fee.
If, for example, the schedule fee for a service is $1000 then the 85% benefit would be $850, which means that the gap is $150. In this case the GPG would apply and the patient would receive a Medicare benefit of $901.30, not $850 (i.e. $1000 minus the GPG of $98.70).
The benefit payable for those items meeting the threshold is the MBS fee less the GPG amount. The GPG amount is to be rounded up to the nearest multiple of 5 cents.
You don’t need to do anything – Services Australia automatically applies the GPG when paying your rebate.
Original Medicare Safety Net (OMSN)
Your gap expenses count towards the OMSN.
Once your gap expenses reach the threshold in a calendar year, Medicare will reimburse you 100% of the schedule fee (instead of 85%) for any further out-of-hospital medical services you need that are subsidised under the MBS.
If your health practitioner charges more than the schedule fee, you may still incur an out-of-pocket cost.
For 2024, the OMSN threshold is $560.40. We review it each year on 1 January, in line with any rise in the cost of living (consumer price index).
If you’re an individual, you don’t need to do anything – you’ll automatically get the higher rebate once you reach the threshold. If you’re a family, you need to let Services Australia know, so they can record your family’s combined expenses.
Read more about the OMSN.
Extended Medicare Safety Net (EMSN)
Your out-of-pocket expenses count towards the EMSN.
Once your out-of-pocket expenses reach the threshold in a calendar year, Medicare will cover up to 80% of any further out-of-pocket expenses you have for out-of-hospital medical services that are subsidised under the MBS.
A number of out-of-hospital services have a cap on how much Medicare will pay. This means that if your out-of-pocket expenses are higher than that cap, the amount you get back might be lower than 80%. The EMSN does not affect how much you get from your private health insurance.
For 2024, the EMSN thresholds are:
- $811.80 for people who have a concession card or get Family Tax Benefit Part A
- $2,544.30 for others.
We review these each year on 1 January, in line with any rise in the cost of living (consumer price index).
If you’re an individual, you don’t need to do anything – you’ll automatically get the higher rebate once you reach the threshold. If you’re a family, you need to let Services Australia know, so they can record your family’s combined expenses.
Read more about the EMSN.