Module 4 - Support Services Flashcards
True or false:
The costs of routine visits to the ophthalmologist (eye specialist) for people with macular disease is a potentially expensive exercise
True.
What is the Medicare Schedule Fee and Medicare Rebate?
The schedule fee is the amount defined by the government as a fee for each of these services. The Medicare Rebate you receive is calculated as a percentage of the Medicare Schedule Fee as follows:
- 85% for all other out-of-hospital services provided by a medical practitioner
- 75% for in-hospital services you receive as a private patient.
What is the Original Medicare Safety Net?
The difference between the schedule fee (the fee set by Medicare) and the benefit paid by Medicare is known as the gap amount.
Once the total gap amount for all non-hospital Medicare items exceeds the Original Medicare Safety Net threshold in a calendar year, the Original Medicare Safety Net will refund 100% of the schedule fee for subsequent non-hospital Medicare items.
In 2021, the Original Medicare Safety Net threshold is $481.20.
What is the out-of-pocket cost?
Ophthalmologists may charge more than the schedule fee. The difference bewteen the opthalmologist fee and the Medicare benefit is the out-of-pocket cost. Remember, this is different to the gap amount, which is the different between the scedhuled fee and the benefit.
What is the Extended Medicare Safety Net?
Once total out-of-pocket costs for all non-hospital Medicare item exceed a certain threshold in a calendar year, the Extended Medicare Safety Net (EMSN) refunds the relevant Medicare benefit plus a further benefit of 80% of out-of-pocket costs for non-hospital Medicare items.
In 2021, the threshold for out-of-pocket costs are $697.00 for concession card holders, and $2,184.30 for non-concession.
What is the PBS Safety Net?
In addition to the consultation, diagnostic and injection fees, people may also incur medication costs associated with the medications used with the injection. Typically, one of Lucentis, Eylea or Ozurdex is used where blood and fluid is present in the macula.
The PBS Safety Net applies once costs in a calendar year for all PBS medications exceed $316.80 (concession) or $1,486.80 (nonconcession). After reaching the PBS Safety Net, subsequent PBS scripts will be free (concession) or $6.60 (non-concession) for the rest of the calendar year
Scenario 1 - Patient has not reach the Extended Medicare Safety Net Threshold
If an ophthalmologist has charged $400 for an injection (item 42738), the calculations below will apply.
The Medicare schedule fee for this item is $312.95. If they have not reached the Original Medicare Safety Net, Medicare will pay 85% of the schedule fee. A patient will thus recieve $266.05 for this item.
The gap is the difference between the schedule fee and the benefit which in this case is $46.90. Once this gap amount reaches $481.20, they will recieve 100% of the schedule fee of $312.95.
The out-of-pocket expense is the difference between the fee the ophthalmologist has charged and the Medicare benefit. The out-of-pocket expense is thus $133.95 ($400 - $266.05).
Because of this high out-of-pocket expense, patients are more likely to reach the Extended Medicare Safety Net first. We will next consider how much someone may pay for the same injection once they have reached the Extended Medicare Safety Net Threshold.
Scenario 2 - Patient has reached the Extended Medicare Safety Net Threshold
If an ophthalmologist has charged $400 for an injection (item 42738), the calculations below will apply.
The Medicare schedule fee for this item is $312.95. If they have not reached the Original Medicare Safety Net, Medicare will pay 85% of the schedule fee. A patient will thus recieve $266.05. If they have reached the Original Medicare Safety Net, they will recieve $312.95
The gap is the difference between the schedule fee and the benefit which in this case is $46.90, or nothing if they have reached the Original Safety Medicare Threshold.
The out-of-pocket expense is the difference between the fee the ophthalmologist has charged and the Medicare benefit. The out-of-pocket expense is thus either $133.95 or $87.05 if they have reached the Original Medicare Safety Net.
As they have reached the Extended Medicare Safety Net Threshold, they are eligible for an 80% rebate on out-of pocket expenses. Thus, Medicare will pay 80% of $133.95 or of $87.05 if they have reached the Original Medicare Safety Net. Thus Medicare will pay an additional $107.16 or $69.64 on top of the Original Medicare Safety Net.
For this item, charged at $400, a patient will thus only pay either $26.79 or $17.41 if they have reached the Original Medicare Safety Net.
Scenario 2 - Patient has reached the Extended Medicare Safety Net Threshold
If an ophthalmologist has charged $400 for an injection (item 42738), the calculations below will apply.
The Medicare schedule fee for this item is $312.95. If they have not reached the Original Medicare Safety Net, Medicare will pay 85% of the schedule fee. A patient will thus recieve $266.05. If they have reached the Original Medicare Safety Net, they will recieve $312.95
The gap is the difference between the schedule fee and the benefit which in this case is $46.90, or nothing if they have reached the Original Safety Medicare Threshold.
The out-of-pocket expense is the difference between the fee the ophthalmologist has charged and the Medicare benefit. The out-of-pocket expense is thus either $133.95 or $87.05 if they have reached the Original Medicare Safety Net.
As they have reached the Extended Medicare Safety Net Threshold, they are eligible for an 80% rebate on out-of pocket expenses. Thus, Medicare will pay 80% of $133.95 or of $87.05 if they have reached the Original Medicare Safety Net. Thus Medicare will pay an additional $107.16 or $69.64 on top of the Original Medicare Safety Net.
For this item, charged at $400, a patient will thus only pay either $26.79 or $17.41 if they have reached the Original Medicare Safety Net.
Are there a number of government supports for someone living with macular disease?
Yes.
What is the ‘Blind Pension’
The blind pension refers to either the Disability Support Pension (Blind) or the Age Pension (Blind). If a person is under 66 years and 6 months, and legally blind, they are eligible for the Disability Support Pension (Blind). If they are aged 66 and 6 months or older, and legally blind, they are eligible for the Age Pension (Blind).
An optometrist or ophthalmologist will need to determine if someone is considered legally blind.
Both pensions are paid at the same amount with no assets or income tests applied (unless also claiming rent assistance). If someone is already receiving the full Disability Support Pension or Age Pension, they won’t receive any additional income from the blind pension.
The rules for pensions are complex, and the best advice you can give someone enquiring about payments is to refer them to Centrelink for advice.
What is the Companion card for carers?
A person who cares for someone with legal blindness may be eligible for a state and territory Companion Card. The Companion Card allows someone to go to venues and activities with the person they are caring for, without having to buy a second ticket.
What are public transport subsidies?
If someone is legally blind, they may be eligible for public transport subsidies. This can include discounts for taxis, trains and buses. This would vary in each state.
What is My Aged Care?
My Aged Care is the main entry point to Australia’s aged care system. Through My Aged Care people can access information on aged care support services, have their needs assessed, and find service providers.
Support can be short-term or ongoing. It can include help with daily living such as assistance with daily chores, health care, accommodation in aged care homes, and equipment for daily living. The Australian Government subsidises many types of aged care services for those who are eligible. An assessment will need to be made prior to determining what level of funding someone may receive
What is My Aged Care?
My Aged Care is the main entry point to Australia’s aged care system. Through My Aged Care people can access information on aged care support services, have their needs assessed, and find service providers.
Support can be short-term or ongoing. It can include help with daily living such as assistance with daily chores, health care, accommodation in aged care homes, and equipment for daily living. The Australian Government subsidises many types of aged care services for those who are eligible. An assessment will need to be made prior to determining what level of funding someone may receive
