The Medicare Safety Net is not something that usually plays a role in anaesthetic practice – but it can pay to understand what it is.
First things first. You need to understand how Medicare determines rebates. In the Medicare Benefits Schedule, each item number has a Schedule Fee. Basically, this is how much the Department of Health thinks that each service is worth (don’t laugh when you see the amounts!).
From each Schedule Fee, the Patient Benefit is determined. For all inpatient services, such as anaesthetics in a private hospital, the Benefit is 75% of the Schedule Fee. This is the Medicare contribution to your fees, and hence will be the rebate the patient receives if they were uninsured. If they are insured, health funds must top this up as a minimum to the Schedule Fee, but it most circumstances, the reality is that they pay a lot more.
For outpatient services, such as consulting patients in your rooms, the Benefit is 85% of the Schedule Fee.
Let take 17615 as an example. The Schedule Fee is $95.60. Regardless of the fee you charge, an uninsured inpatient will receive a Medicare rebate of $71.70 and a patient you see as an outpatient will receive $81.30.
You can find these amounts at mbsonline.gov.au.
As the name implies, Medicare has a system for those who have high expenditure on their healthcare. These are designed to support patients that have high out-of-pocket expenses. There are two Safety Nets – the Original Medicare Safety Net and the Extended Medicare Safety Net. Both only apply to outpatient (or “out-of-hospital”) services only.
The Original Medicare Safety Net (OMSN) records the out-of-pocket expenses paid by an individual or a family and once their expenses reach the threshold in a calendar year, they receive the full Schedule Fee as a rebate. The threshold for individuals and families as at 01 January 2024 is $560.40 and are indexed to CPI annually.
Therefore, if a patient has qualified for the OMSN and sees you in your rooms for a 17615 consultation, they receive a rebate of $95.60 regardless of how much you charge them.
The Extended Medicare Safety Net (EMSN) provides further rebates on out-of-pocket expenses. These have higher thresholds per calendar year as at 01 January 2024:
Once the threshold is reached, the EMSN provides a rebate of 80% of the out-of-pocket expense in addition to the original rebate. Some items have EMSN caps for each item number, being the maximum additional rebate that will be paid by Medicare. These tend to be consultation item numbers. RVG item numbers do not have a EMSN cap, therefore, if you a providing anaesthesia services in an outpatient setting, the patient will be eligible for EMSN rebates if they have reached the threshold. These caps are detailed in the MBS.
Looking at our previous example of 17615, the EMSN cap is $286.80. So if the total fee charged was $500, then the patient would be entitled to a Medicare rebate of $81.30 plus $286.80.
Note that the patient must pay the fee in full to the provider prior to submitting a Medicare claim, otherwise the out-of-pocket expense will not count towards the threshold, and they will not receive the Safety Net rebates.
Medicare has additional rebates for patients with high accumulated out-of-pocket expenses through Safety Nets. For anaesthetists, this will apply to consultations and anaesthesia services in the outpatient setting.
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