How they work

Medicare Safety Nets have thresholds. These are the dollar amounts you need to reach in gap and out of pocket costs to be eligible. When you’re eligible, you’ll start getting higher Medicare benefits. This means you’ll get more money back from us for certain Medicare services. 

A Medicare benefit is the dollar amount we pay you when you’ve made a claim for a medical service. This is usually 85-100% of the schedule fee. A schedule fee is the dollar amount the Australian Government sets for each medical service. The MBS Online website lists the schedule fee amount.

The threshold amounts are set each year from 1 January.

There are 2 Medicare Safety Nets:

• Original Medicare Safety Net
• Extended Medicare Safety Net

Original Medicare Safety Net

If you’re enrolled in Medicare you’re eligible for the Original Medicare Safety Net (OMSN).

Your gap amount counts towards your OMSN threshold. A gap amount is the difference between:

• the Medicare benefit you get
• and the schedule fee for out of hospital medical services.

When you reach the threshold, you’ll get a higher benefit back. You’ll get 100% of the schedule fee for out of hospital services for the rest of the calendar year.

If you’re an individual we’ll automatically pay you the higher Medicare benefit when you reach the threshold.

If you’re part of a registered family, you’ll need to confirm your family members. You’ll need to do this before we’ll pay you a higher Medicare Safety Net benefit.

Extended Medicare Safety Net

If you’re enrolled in Medicare you’re eligible for the Extended Medicare Safety Net (EMSN).

Your out of pocket costs count towards your EMSN threshold. Out of pocket costs are the difference between the following:

• the Medicare benefit you get back
• the doctor’s fee for out of hospital medical services.

The EMSN has 2 thresholds:

• General
• Concessional and Family Tax Benefit Part A.

General Threshold

When you reach the General Threshold, your benefit will apply to out of hospital medical services. This will apply for the rest of the calendar year. You’ll get the Medicare benefit and the lowest of the following:

• 80% of the out of pocket amount
• Extended Medicare Safety Net benefit caps.

You can read more about the EMSN benefit caps on the Department of Health website.

If you’re an individual we’ll pay you the higher Medicare benefit when you reach the threshold.

If you’re part of a registered family, you’ll need to confirm who’s in your family. When you do this, we’ll start paying you a higher Medicare benefit.

Concessional and Family Tax Benefit Part A Threshold

You may be eligible for the lower threshold if you’re any of the following:

• a Commonwealth Seniors Health Card holder
• a Health Care Card holder
• a Pensioner Concession Card holder
• eligible for Family Tax Benefit Part A.

The date you become eligible for the EMSN Family Tax Benefit Part A depends on your payment. To find out more, read Eligibility for FTB Part A Safety Net benefits.

You may be part of a registered Medicare Safety Net family and eligible for the concessional threshold. When this happens you may also be part of a concessional family. To find out more, read about concessional families.

When you reach the concessional threshold, your benefit will apply to out of hospital medical services. This will apply for the rest of the calendar year. You’ll get the Medicare benefit and the lowest of the following:

• 80% of the out of pocket amount
• Extended Medicare Safety Net benefit caps.

You can read more about the EMSN benefit caps on the Department of Health website.

If you’re an individual we’ll pay you the higher Medicare benefit when you reach the threshold.

If you’re part of a registered family, you’ll need to confirm who’s in your family. When you do this, we’ll start paying you a higher Medicare benefit.

Next: How to manage your Medicare Safety Nets

How to check your Safety Net threshold, and let us know if your family situation changes.