Ok I'm dumb. Someone explain the Medicare Safety Net to me...

[Indadhanu]

I knew all this. Once. Before I had Jazz. When we were trying to conceive her I knew all about the Medicare Safety Net.

Now, no matter how slowly someone explains it to me I am not getting it. And they don't understand my questions.

Ok, so my vague, fuzzy memory tells me that the Medicare Safety Net used to go like this:
You haven't yet hit the safety net threshold. You get medical stuff done. Pay the doctors (or whoever). Then you go to Medicare and they give you the medicare benefit fee back.
So now you go to the doctor, only this time you've seen HEAPS of doctors, and you've paid HEAPS, and all of your out-of-pocket expenses equal a certain about, which is over the safety net threshold, so after you pay your doctor and you go in the Medicare they pay you the Medicare benefit AND then they give you more because you've paid so much in medical expenses already.
Pretty sure once you hit the safety net threshold it was something like 80% of the out-of-pocket.

Now... is this how it is? Or at least was? Or is my brain confusing it.

I'm confused when people start talking about the threshold because I keep asking them, what's the threshold? I'm sure it was something like $1000. So once you had paid, say, $1000 in total medical expenses, then they started giving you more back when you claimed.
I mean total, as in, all your expenses in the financial year.

Now people look at me stupidly. They go on, and the general gist I'm getting is that there is no total threshold, that the threshold is just on the one service you are paying for now. It also seems a lot lower now.

So someone explain it to me. And the Extended Medicare Safety Net? And the FTB(A) Safety Net? UGH! I'm so confused!

[anney]

Your explanation sounds spot on to me. this is from the medicare website:



What is the Medicare Safety Net?
The Medicare Safety Net provides families and individuals with financial assistance for high out-of-pocket costs for out-of-hospital Medicare Benefits Schedule (MBS) services. Once you meet a Medicare Safety Net threshold, you may be eligible for additional Medicare benefits for out-of-hospital MBS services for the rest of the calendar year. Also available is the PBS Safety Net if you and your family need a lot of medicines in any year.

Medicare Safety Net thresholds as at 1 January 2010
Threshold amount Who it is for How it is calculated What the benefit is
Original $388.80† All Medicare cardholders Based on gap amount 100% of schedule fee for out-of-hospital services
Extended concession and FTB(A) $562.90† Concession cardholders and families eligible for FTB(A) Out-of-pocket costs 80% of out-of-pocket costs or the EMSN benefit cap for out-of-hospital services
Extended general $1126.00† All Medicare cardholders Out-of-pocket costs 80% of out-of-pocket costs or the EMSN benefit cap for out-of-hospital services

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.

What is an Extended Medicare Safety Net (EMSN) benefit cap?
An EMSN benefit cap is an upper limit on the amount of Medicare Safety Net benefit payable for an out-of-hospital MBS service. Not all Medicare items have an EMSN cap.

For more information about the EMSN benefit cap go to the Extended Medicare Safety Net fact sheet on the Department of Health and Ageing's MBS Online website.

What are the benefits for me?
Once you reach a Medicare Safety Net threshold visiting a doctor or having tests may cost you less.

For example: if you reach a threshold and then visit your doctor who charges you $65.00 for a standard consultation, you will receive your Medicare benefit of $34.30. You will also receive 80 per cent of your out-of-pocket costs (($65.00 - $34.30) x 80 per cent), giving you an extra $24.60. So in this example it will only cost you $6.10 to visit your doctor. An out-of-pocket cost is the difference between the Medicare benefit and what your doctor charges you.

[Indadhanu]

So.
This confused me because if the threshold is the limit you have to reach, why is the concession threshold higher then the general threshold?
Or is this a new 'threshold' of benefits, meaning that is the maximum you get back, regardless of what you pay? Have they put a cap on how much of your out of pocket expenses you get back? So it's 80% OR that threshold amount, whichever is lower?

[Indadhanu]

So what is the threshold amount? We have to pay $562.90 out-of-pocket before we start to get 80% back of out OOP expenses?

So we do IUI for $1224. The Medicare Benefit is about $500. So we are OOP about $724 (well a lot more... More like $1800, but that extra $1050 isn't Medicare eligible UGH!). So anyway, on our first cycle, are we eligible for a percentage back of our OOP expenses over $564.90? So a percentage back on $159? And on our next cycle, since we have reached the threshold of $562.90 on our last cycle, do we get a percentage back on our full OOP expenses?
I tried to ask Medicare but she looked like I was asking her if she could explain how to build a ladder to the moon.


OR... do we get 80% back, UP TO $564.90? So 80% of our OOP would be $579.20. So would we only get back $564.90?
If this is the case, is there no OOP threshold we have to reach to be eligible to get 80% back?

I'm so confused

[Trillian]

It is confusing isn't it? You do have it right in your last post - once your Total out of pocket reaches that threshold amount, then you will get more back on each claim after that. And it is only in a calendar year too. So you should reach it pretty quickly, if not be there already by now.

[Hollybolly]

Leash, they have put a cut off amount on certain things.... IVF, IUI, Assisted Conception & Obstetrics.
Its just a flat amount of approx $500. (So as far as I understand it, no gap plus a percentage of OOP... just a flat rate).

For example, if I were to do an IVF cycle this year (say I'd passed my threshold) - before where we used to pay $6500 for a cycle, we'd get back roughly $5000. (Normal medicare gap plus 80% of OOP)
Now, regardless of what the cycle will cost us, we only get back a set amount (I think its about $482 )

So although you guys may have reached your limit, you won't necessarily get back the 80% (unless the 80% is roughly what the set amount is).. god, does any of that make sense?!

I think that is per cycle, not a once only for the year... but I really don't know for sure

Geeez, what a jibberish post

[Indadhanu]

Ohhhhhhhhhhhhhhhhhhhh Holly, that actually makes more sense to me, that must be what the coordinator must have been trying to explain! What a PITA! We are paying more this time around but getting back less. Last time we paid $1000 a cycle but got $800 back once we hit the threshold. Now we're paying over $2000 a cycle and probably only get $600 back (if that's what the nurse was explaining).

Hey Holly, do you know, with the ENFY tax medical expenses rebate... we had to use a donor from the USA this time. Importing the sperm ($1050 a month, for a 10mL ampuole! ) isn't able to be claimed from Medicare, but can we claim it at the end of the financial year? I haven't asked that one yet, I only just found out about the rebate thing (20% of costs over $1500?).

[Hollybolly]

I'm not 100% on the EOFY tax rebate... I think you get a certain percentage back of what you've spent in general.
I don't think its exceptionally generous either - but as I understand it, its an amount thats capped as well
So even if your sperm or its 'importation' may not be covered because of medicare, chances are the costs surrounding it (like storing) may be.
If you spend enough overall in the cycle (which you will), you'll prob find that the other costs will allow you to get back the max available to claim....
I'm not 100% though, sorry!!!!

[Indadhanu]

Haha thats ok, just wondering. It's all changed so much since 3 years ago! Hope it doesn't take too long, my CC will probably self-destruct after a few months...