Calculation of Extended Medicare Safety Net (EMSN) benefits

About how to calculate Extended Medicare Safety Net (EMSN) benefits.

Page last updated: 07 February 2017

Uncapped services

The following scenario assumes that the patient has already reached their Extended Medicare Safety Net (EMSN) threshold and is therefore eligible to receive EMSN benefits. To calculate the Extended Medicare Safety Net (EMSN) benefit for an uncapped Medicare Benefits Schedule (MBS) service (see MBS Online for capped and uncapped items), follow these three steps:
  1. calculate the out-of-pocket expenses for the service as (fee charged by provider) – (out-of-hospital MBS benefit- see MBS Online for details)
  2. multiply the out-of-pocket expenses for the service by 80 per cent (or 0.8)
  3. round the result up to the nearest 5 cents.

Capped services

The following scenario illustrates how the EMSN caps work. The scenario assumes that the patient has already reached their EMSN threshold and is therefore eligible to receive EMSN benefits and uses MBS item 16500 - an antenatal attendance as the basis for the example.

For services provided in 2017 this item has an:
  • MBS fee of $47.15
  • out-of-hospital MBS benefit of $40.10
  • EMSN benefit cap of $32.95.

Example 1:

If the doctor charges $70.00 for the service, the patient’s out-of-pocket cost before EMSN benefits are paid is $29.90 (fee charged by provider minus the MBS benefit received). The EMSN benefit for this service is calculated to be $23.95 (80% of the patient’s out-of-pocket cost and is rounded up to the nearest 5 cents). As the calculated EMSN benefit is below the EMSN benefit cap amount of $32.95, the patient will receive the full $23.95 in EMSN benefits. As a result, the total cost incurred by the patient is $5.95.

Example 2:

If the doctor charges $90.00 for the service, the patient’s out-of-pocket cost before EMSN benefits are paid is $49.90 (fee charged by provider minus the MBS benefit received). The EMSN benefit for this service would be calculated to be $39.95 (80% of the out-of-pocket cost and is rounded up to the nearest 5 cents) however, as this item has an EMSN benefit cap, the patient will receive the cap amount of $32.95. As a result, the total cost incurred by the patient is $16.95.

The Department of Human Services (DHS) automatically calculates the accumulation of out-of-pocket costs to the relevant threshold and the calculation of benefits. Families can register with DHS as a ‘safety net family’ to be able pool their out-of-pocket costs towards a shared threshold. While some MBS items have an EMSN cap, there is no limit on the total EMSN benefits each person can receive in a calendar year.