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Medicare Safety Net
Please help me understand!

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16 replies to this topic

#1 NinjaMum

Posted 01 January 2013 - 11:16 AM

2012 we hit the medicare safety net due to specialist appointments. I didn't question much, just took it gratefully, and went on our merry way.

However, now it's 2013 and we're back to starting from scratch on the safety net. I have looked at the Dept. Human Services website, and I don't understand it. I am wanting to try and calculate how long it will take us to hit the safety net this year. DH has a weekly Psychiatrist appointment costing $280, plus will probably have a few GP and other specialist appointments in the first few months of the year.

The website talks about 3 different thresholds:

  • Original - $421.70
  • Concessional & FTB A - $610.70
  • Extended General - $1221.90

How do I know which one is the threshold for our family/My DH? We don't qualify for FTB A, so I'm ignoring that one. I'm guessing it will be the Extended General threshold which will apply to us? I'm also looking at keeping tabs on the PBS safety net too, as he has been on a fair bit of medication this past 12 months.

Any help to understand this, is gratefully appreciated!

#2 Acidulous Osprey

Posted 01 January 2013 - 11:23 AM

You would be on the Extended and once you have paid out the $1221.90 in gap fees (the gap between the specialist fee and the medicare refund) you will be eligible for the safety net.

To calculate it, look at how much you paid and the difference in how much you got back.  So if the bill is $280 and medicare refund $120, the remaining $160 goes to the safety net.

The medication one takes a lot to fill.  I've got 3 people on several meds each and we only reach it in October usually.

#3 Isolabella

Posted 01 January 2013 - 11:23 AM

Yep you would be on extended general of $1221.90

So that is out if pocket expenses after Medicare has paid you claim.

Eg Dr bill of $70. Medicare pays $35 so you ave $25 go towards your threshold of $1221.90. Medicare will automatically increase your payments once you reach the threshold.

PBS if you use one pharmacy should be able to tell you where you are at. Also you can ask Medicare how close you are to the threshold.

#4 FeralAlpacaWarrior

Posted 01 January 2013 - 11:30 AM

Can I please ask what is the difference between original and the extended general? Ie how do I know which applies to us? We reached the threshold months ago.

Edited by lovealpacas, 01 January 2013 - 11:31 AM.

#5 Acidulous Osprey

Posted 01 January 2013 - 11:35 AM

I don't know the difference between general and original.

The safety net resets for meds and medicare on Jan 1 every year so we are all back at ground zero. One year we had paid our safety net by Feb 8.  Certainly hoping for a better year this year.

#6 Isolabella

Posted 01 January 2013 - 11:48 AM

Original Medicare safety net
Under the original Medicare safety net, once an annual threshold in gap costs has been reached, the Medicare rebate for out-of-hospital services is increased to 100% of the schedule fee (up from 85%). Gap costs refer to the difference between the standard Medicare rebate (85% of the schedule fee) and the actual fee paid, but limited to 100% of the schedule fee. The threshold for calendar year 2012 is $413.50. This threshold applies to all Medicare-eligible singles and families.


So there is another sub tier. Normally Medicare pays you 85% of their scheduled fee ( ie Medicare scheduled fee not what Dr charges). So if Medicare says scheduled fee is $50 you initially get $42.50, but once you hit $400 or soo of the $7.50 difference you then get back the full $50. But this will be whether your Dr is charging you $90 for the appt. One you hit the $400 or so of the 15% difference you would get 100% of the Medicare rebate payable....... But you still have to hit the $1221 valve to get 80% of you out of pocket fees back ( ie difference between what Medicare pays you vs what the Dr charges).

So the first threshold will not substantially change what you get back if you Dr charges high above Medicare Sch fee.

#7 Coffeegirl

Posted 01 January 2013 - 11:52 AM

From what I can tell the general is based on the accumulation of the GAP amount, but the Extended General is based on your Out-of-pocket

Out-of-pocket costs—the difference between the Medicare benefit and what your doctor charges you.

Schedule fee—a fee for service set by the Australian Government.

Gap amount—the difference between the Medicare benefit and the schedule fee.

#8 NinjaMum

Posted 01 January 2013 - 01:44 PM

Ugh, it's a bit confusing isn't it.

Thank you so much PPs for taking the time to try and explain it! It sounds like I should just ignore the Original one, and calculate it from the Extended one. This would mean by my estimate we'll hit the safety net during March some time.

We use different pharmacies (it's really whatever pharmacy is on my way to wherever I happen to be going when DH is close to running out of medication) so for the PBS I'm of the understanding I will have to keep a piece of paper with labels on it(?) and keep a physical tally. I'm not sure if we'd reach the PBS or not though, as I honestly don't know how much of it we covered last year. I do know some of DH's medications were capped at $35.40.

#9 JRA

Posted 01 January 2013 - 06:59 PM

you shouldnt need to keep track of the medicare one, the do that, so as soon as you hit, the change the refund

#10 Sloane Peterson

Posted 01 January 2013 - 07:07 PM

I just received a letter from Medicare dated December 28, received December 31, advising me,that my family was 'close' to reaching the safety net threshold for the 2012 year, and could I please confirm some details!  happy.gif

#11 elmo_mum

Posted 01 January 2013 - 07:16 PM

Sloane Peterson Posted Today, 08:07 PM
I just received a letter from Medicare dated December 28, received December 31, advising me,that my family was 'close' to reaching the safety net threshold for the 2012 year, and could I please confirm some details!


#12 NinjaMum

Posted 02 January 2013 - 09:50 AM

JRA - I know I don't need to keep track of it, but it will help with budgeting. It means a couple of really financially tight months for us until the Safety Net kicks in, so it's more of a light at the end of the tunnel kind of thing. The PBS on the other hand, I've been led to believe I do need to keep a track of this one?

Sloane Peterson - At least they're efficient? laughing2.gif

#13 Futureself

Posted 02 January 2013 - 10:02 AM

QUOTE (NinjaMum @ 02/01/2013, 09:50 AM) <{POST_SNAPBACK}>
The PBS on the other hand, I've been led to believe I do need to keep a track of this one?

Yes, you do as there's no centralised prescription system. Pick up your card with your first script and then keep it with your repeats. Every time you get a script done (seperate cards per person), give them the card too to get the script sticker put in. Once you've filled it the pharmacy you've gone to will keep it to process and it will added centrally then. Painful but necessary if you want to be sure. The other option, if you only go to 2 or 3 different places is to stop by and get a printout every few months or half way through the year  from each to see how you're going and you can hand the printoust showing the totals to the one place once you've reached the threshold to be processed.

#14 elizabethany

Posted 02 January 2013 - 10:02 AM

The medication safety net hits once you have filled 52 scripts on PBS in any given year.  Scripts where you pay the full fee do not count towards this safety net.  You need to keep a record of this, and you can get your pharmacist to give you a small folder, so you just present this wherever you fill your scripts.


#15 notorico

Posted 04 January 2013 - 04:55 PM

I am not 100% sure how it works, but towards the end of last year we as a family were getting close to the extended limit. DS however, who has a healthcare card, reached some sort of individual limit earlier in the year so I was getting the extra back for him only, but appointments for the rest of the family were only getting the basic medicare entitlement.

Hope this helps, perhaps you could call and ask. DS starts back at his regular psych appointments next week and I am not looking forward to the out of pockets now the safety net has been reset.

#16 FeralLIfeHacker

Posted 04 January 2013 - 07:53 PM

I am confused as well, I've never worried about it before but since I now take handfuls of meds daily I thought I should check it out.  I think I will ask about the PBS one at the pharmacy. I think dh asked him last year and he said to come in January and he'd give us a card to keep and present when filling the scripts.

#17 leo the lioness

Posted 13 January 2013 - 03:34 PM

QUOTE (Sloane Peterson @ 01/01/2013, 08:07 PM) <{POST_SNAPBACK}>
I just received a letter from Medicare dated December 28, received December 31, advising me,that my family was 'close' to reaching the safety net threshold for the 2012 year, and could I please confirm some details!  happy.gif

Same thing happened to me except mine was dated 21 December and I didn't receive it until the 3 January 2013!

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