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Medicare and PBS Safety Nets

Medicare Safety Net

The Medicare Safety Net provides individuals and families with reimbursement of out of pocket (gap) expenses for out of hospital services, such as GP and specialist consultations, psychiatry, and tests and scans. The Safety Net does not apply to services for which a Medicare benefit is not payable.

There are two thresholds: original and extended. Once the original threshold is reached, Medicare will reimburse you for 100% of the Scheduled Fee for all eligible out of hospital services for the remainder of the calendar year. Once the extended threshold (standard or concessional) is reached, Medicare will reimburse you for 100% of the Scheduled Fee plus 80% of the difference between the Scheduled Fee and the actual fee paid on all eligible services for the remainder of the year. Since January 2010, these payments have been subject to caps in certain areas, such as assisted reproduction and cataract operations.

Individuals are automatically registered for the Medicare Safety Net. However, eligible families can optionally register so that their medical costs can be counted together. The thresholds for registered families are the same as the thresholds for individuals, so depending on your circumstances it may be highly advantageous for your family to register. However, children who are not studying may not be able to register as a family member.

Individuals who hold a Commonwealth concession card (such as the Pensioner Concession Card and the Low Income Health Care Card) and/or registered families who receive Family Benefit Tax Part A are eligible for a concessional extended threshold, which is approximately 50% of the standard extended threshold. In cases where the family as a whole is only eligible for the standard extended threshold but two or more family members qualify for the concessional extended threshold, special rules apply.

More information about the Medicare Safety Net is available at the Medicare Australia website.

 

Pharmaceutical Benefits Scheme (PBS) Safety Net

The PBS Safety Net provides individuals and some families with assistance in circumstances where they need to purchase a lot of medication. The Safety Net does not apply to medications which are not covered by the Pharmaceutical Benefits Scheme.

Under the Pharmaceutical Benefits Scheme, patients pay a co-contribution towards the actual cost of medications. The PBS Safety Net takes effect when PBS co-contributions for the calendar year exceed the relevant threshold (standard or concessional). All individuals and registered families are entitled to pay the concessional co-contribution rate for medications once they exceed the standard threshold. In addition, individuals and families who are eligible for the Medicare Safety Net's concessional extended threshold are usually entitled to an exemption from further co-contributions once they exceed the PBS Safety Net's concessional threshold. The concessional threshold is approximately 25% of the standard threshold. As with the Medicare Safety Net, families who register may count their prescription co-contribution costs together. However, family registration is done through your pharmacy, rather than with Medicare directly.

Unlike the Medicare Safety Net, for the PBS Safety Net it is your responsibility to keep a record of your medication purchases throughout the year. If your family uses a single pharmacy, your pharmacist may be able to keep these records for you by request. In all other circumstances, you need to obtain a Prescription Record Form, which is available from most pharmacies, and provide this form when paying PBS co-contributions. When you (or your family) nears the relevent Safety Net threshhold, you can ask your pharmacist to help you apply for the appropriate entitlement card1.

More information about the PBS Safety Net is available at the Medicare Australia website.

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1 PBS Safety Net: A Pharmacist's Guide (2011)

This page last updated on 07/07/11 @ 12:16AM.

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