[NinjaMum]

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!

[Sinister Bonnet]

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.

[lsolaBella]

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.

[lovealpacas]

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.

This post has been edited by lovealpacas: 01/01/2013, 11:31 AM

[Sinister Bonnet]

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.

[lsolaBella]

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.

http://en.wikipedia.org/wiki/Medicare_(Australia)

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.

[Bacongirl]

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.

[NinjaMum]

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.

[JRA]

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

[Sloane Peterson]

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!