MBS, PBS &
insurance
Medicare & PBS
safety nets
Medicare Safety Net was introduced in 1984 to reduce high out-of-pocket costs of cardholders who require frequent out-of-hospital services. The Original Medicare Safety Net entitles you to receive 100% of the MBS Schedule Fee (instead of 85%) once the prescribed threshold is met.
Under the PBS, many critical medications (including those for IVF) are heavily subsidised by tax payers. If you've reached the PBS Safety Net for the calendar year, your PBS medication cost will be further reduced. See Table A: Thresholds & Benefits for Safety Nets.
What is Extended Medicare Safety Net (EMSN)?
EMSN is additional benefits (up to 80% total out-of-pocket costs) you receive on top of the standard benefits once the prescribed threshold is met. You can meet the threshold sooner if you're registered as a couple/family. In-hospital services are not eligible for EMSN.
If you have accumulated out-of-pocket expenses paid towards the EMSN threshold but have not reached the required amount for the calendar year, your next claimable Medicare item(s) may still be eligible for EMSN pursuant to Sections 10ACA / 10ADA of the Act. See calculation examples.
To check your Medicare Safety Net balance, visit myGov or register here
What is EMSN Benefit Capping?
EMSN benefit capping imposes a maximum amount on EMSN benefits you'll receive for a MBS item (see Table B: IVF/ICSI Cycle Benefits).
Since 2010, Medicare items for Assisted Reproductive Technology and obstetrics have been capped after the Extended Medicare Safety Net Review Report in 2009 showed that "...the EMSN had been used by specialist doctors to raise their fees knowing the taxpayer would cover 80 percent of the fee rise...The EMSN benefit is intended to be a patient benefit; it is not intended to be a mechanism for doctors to increase their fees" (Fact Sheet: Medicare Safety Net Arrangement - 1 January 2019)
thresholds &
benefits
Table A
Types of Safety Net
Threshold
Amount
(indexed annually on 1 Jan)
How to meet the threshold (calculated from 1 Jan to 31 Dec)
Benefits once threshold
is met
(for the rest of the calendar year)
Original Medicare
Extended Medicare
(General)
Extended Medicare
(Concessional &
Family Tax Benefit
(FTB) Part A)
PBS
(General)
PBS
(Concessional)
As at 1 Jan 2020
Source: MBS & PBS
$477.90
$2,169.20
$692.20
$1,486.80
$316.80
Based on gap amount paid.
Gap amount is the difference between the MBS schedule fee and the Medicare benefit you receive.
Based on out-of-pocket expenses paid.
Out-of-pocket expense is the difference between actual doctor/service fees paid and the Medicare benefit you receive.
Based on the PBS amount paid.
You'll receive 100% of the MBS schedule fee.
You'll receive the standard Medicare benefit
PLUS 80% of the out of pocket amount, or EMSN benefit cap amount (whichever is lower).
$6.40 (you must apply for the PBS Safety Net card once you meet the threshold)
FREE (you must apply for the PBS Safety Net card once you meet the threshold)
$
IVF / ICSI cycle
Medicare benefits
Table B: IVF
Cycle
Type
Item
No.
Item Description
Standard
Benefits
EMSN
Benefit Cap
Total Benefits
if EMSN is met in same calendar year
IVF
1st cycle
in calendar
year
13200
13209
13212
13215
Global Fee 1st Cycle
Cycle Management
Egg Pick-up (in-patient)
Embryo Transfer (in-patient)
TOTAL
$3,075.80
$73.15
$270.10
$84.70
$3,503.75
$1,702.30
$11.05
Nil
Nil
$1,713.35
$4,778.10
$84.20
$270.10
$84.70
$5,217.10
increases to $5,217.10 if EMSN Threshold is met for the year
IVF
subsequent cycle
in calendar
year
13201
13209
13212
13215
Global Fee Subsequent Cycle
Cycle Management
Egg Pick-up (in-patient)
Embryo Transfer (in-patient)
TOTAL
$2,871.60
$73.15
$270.10
$84.70
$3,299.55
$2,471.05
$11.05
Nil
Nil
$2,482.10
$5,342.65
$84.20
$270.10
$84.70
$5,781.65
EMSN Threshold is met for the year
As at 1 Jan 2020
Source: MBS Online
INPATIENT Procedure at Day Surgery Hospital
If your egg pick-up/embryo transfer is performed as an INPATIENT procedure, you will likely receive a separate bill from the anaesthetist and hospital. INPATIENT Day Surgery Hospital fees are not covered by Medicare. See private health insurance.
Nevertheless, you will receive Medicare benefits for part of your Anaesthetist fees for the following item numbers:
17610 - Pre Anaesthetic Consult
20943 - Anaesthesia Management
23021/2 - Time Units (16-25min)
Standard Benefits - $123.75
OUTPATIENT Procedure
Some centres include egg collections as part of the treatment costs where it is performed as an OUTPATIENT procedure
under local anaesthesia +/- light sedation.
In this instance, there are no Medicare items claimable or separate bills payable.
Table B: ICSI
ICSI
1st cycle
in calendar
year
13200
13209
13212
13215
13251
Global Fee 1st Cycle
Cycle Management
Egg Pick-up (in-patient)
Embryo Transfer (in-patient)
Intracytoplasmic Sperm Injection
TOTAL
$3,075.80
$73.15
$270.10
$84.70
$361.00
$3,864.75
$1,702.30
$11.05
Nil
Nil
$109.90
$1,823.25
$4,778.10
$84.20
$270.10
$84.70
$470.90
$5,688.00
increases to $5,688.00 if EMSN Threshold is met for the year
ICSI
subsequent cycle
in calendar
year
13201
13209
13212
13215
13251
Global Fee Subsequent Cycle
Cycle Management
Egg Pick-up (in-patient)
Embryo Transfer (in-patient)
Intracytoplasmic Sperm Injection
TOTAL
$2,871.60
$73.15
$270.10
$84.70
$361.00
$3,660.55
$2,471.05
$11.05
Nil
Nil
$109.90
$2,592.00
$5,342.65
$84.20
$270.10
$84.70
$470.90
$6,252.55
EMSN Threshold is met for the year
As at 1 Jan 2020
Source: MBS Online
INPATIENT Procedure at Day Surgery Hospital
If your egg pick-up/embryo transfer is performed as an INPATIENT procedure, you will likely receive a separate bill from the anaesthetist and hospital. INPATIENT Day Surgery Hospital fees are not covered by Medicare. See private health insurance.
Nevertheless, you will receive Medicare benefits for part of your Anaesthetist fees for the following item numbers:
17610 - Pre Anaesthetic Consult
20943 - Anaesthesia Management
23021/2 - Time Units (16-25min)
Standard Benefits - $123.75
OUTPATIENT Procedure
Some centres include egg collections as part of the treatment costs where it is performed as an OUTPATIENT procedure
under local anaesthesia +/- light sedation.
In this instance, there are no Medicare items claimable or separate bills payable.
Cycle
Type
Item
No.
Item Description
Standard
Benefits
EMSN
Benefit Cap
Total Benefits
if EMSN is met in same calendar year
private health insurance
Q: Does my private health insurance cover the treatment cycle fees?
A: No
Q: So, what does my health insurance (with IVF) cover?
A: Possibly - for in-patient egg collection & embryo transfer
It is important to note that private health insurance is not required for fertility treatments. However, most centres perform egg collection and some perform embryo transfer as an In-Patient procedure in their private facility. Hence some costs (eg parts of the anaesthetist's fees, day surgery hospital fees...) are non-Medicare items or you will receive less benefits. This is where your private health insurance with IVF cover might come in handy. Your private health insurance may cover the day surgery hospital fees and the remaining MBS Schedule Fee where Medicare does not pay the full benefit.
When checking with your insurer, you may quote the following item numbers for In-patient procedures:
-
13212 ‘Oocyte Retrieval’ (egg pick up/collection)
-
13215 ‘Embryo Transfer’
The amount covered and excess payable are dependent on your private health insurance cover.
For the purposes of comparison, an excess/gap of $500 (initial cycle) and $200 (subsequent cycle) have been factored in the results. If you do not have private health insurance with IVF cover, the estimated out-of-pocket cost for these in-patient procedures is approximately $2,000.
in summary...
The general sentiments from patients were that centres commonly publish an underestimated total Out-Of-Pocket treatment costs. Having discussed the common cost determining factors above, you'll be better equipped to understand and distinguish future fee quotes.