Medicare and the PBS

Medicare Safety Net

The Medicare Safety Net is designed to protect people who have high medical costs from paying large gap fees. It means that once you have reached the annual threshold, visits to your doctor, or tests outside of hospital may cost you less for the rest of the calendar year. For example, once you reach the threshold, you still pay the same amount upfront to your doctor. However, you may receive a higher Medicare benefit, making your out-of-pocket expenses much less. 

The Medicare Safety Net covers a range of doctors’ visits and tests that you receive out of hospital. It does not apply to any out-of-pocket costs you pay for treatment or tests as an inpatient in hospital. The Medicare safety net threshold is adjusted annually to account for inflation.

Services that count towards the Medicare safety net include:

GP and specialists’ consultations
scans and test such as bone scans, CT scans, X-rays and ultrasounds
blood tests.

Individuals are automatically registered for the Medicare safety net but families and couples need to register to link all individuals as one family. If you have a partner and/or children, you need to register even if you are all listed on the same Medicare card. This is to ensure that the medical costs of all family members are taken into account so you will reach the threshold as soon as possible.

There are three Medicare Safety Net thresholds currently: 

To reach the first safety net threshold, your gap fees (the difference between the schedule fee and the Medicare rebate) for out-of-hospital services must accumulate to a certain amount within a calendar year. Once the threshold is reached, you will receive 100 per cent of the Medicare schedule fee for all out-of-hospital services. However, a person will still have to pay the additional difference if the doctor charges more than the schedule fee.
The second safety net is for concession card holders and families eligible for Family Tax Benefit Part A. Once out-of-pocket costs (the difference between the Medicare benefit and what a doctor actually charges) reach the threshold, Medicare will meet 80 per cent of any further out-of-pocket expenses for out-of-hospital services for the remainder
The third safety net is the extended general safety net. This applies to all Medicare cardholders and comes into play if out-of-pocket costs reach a certain threshold during a calendar year. For any out-of-hospital services beyond this, Medicare will pay 80 per cent of out-of-pocket costs or the extended Medicare safety net benefit cap.

The thresholds are adjusted annually to account for inflation.  If you are concerned about gap fees associated with doctors’ appointments and tests, talk to your specialist about whether you can be bulk billed. Bulk-billing is when your health professional accepts the Medicare benefit as full payment for a service. Many health professionals bulk bill pensioners and Health Care Card holders.

You can also talk to your specialist or service provider about whether they can claim the Medicare rebate on your behalf when you pay your full account so that you don’t need to submit a claim at all. Medicare will then pay the rebate to the provider so that you only need to pay the gap amount.

Pharmaceutical Benefits Scheme (PBS)

The Pharmaceutical Benefits Scheme (PBS) is a federal government system that subsidises the cost of some medications. Everyone who has a Medicare card is covered by the PBS and can access PBS-listed medications at a subsidised cost. The subsidy may not cover all of the cost; individuals usually pay a contribution known as the PBS co-payment, script fee or dispensing fee. This fee is adjusted regularly following government review. There is usually a lower co-payment amount for people who have a Health Care Card or those on a pension.

Some breast cancer drugs that you may hear about are not approved for the PBS and not subsidised. This is particularly common for new drugs that have not been through the extensive PBS approval process.

Some years the PBS prescriptions really mount up quickly. It helps to keep our main pharmacist updated on the receipts from other pharmacies. They can let us know if we’ve reached the PBS Safety Net and help us with explanation and registering

Jenny Anne

Who can help explain the different safety nets and how they might apply to me?

Your pharmacist or Centrelink office can explain the safety nets associated with the cost of medications and medical bills.

Things you can do now

Visit the Services Australia website to read more about the Medicare Safety Nets.
Visit the PBS website for more information about medicines subsidised by the Australian Government.
Visit My Journey, BCNA’s online tool for information tailored to your diagnosis
Join our Online Network if you think that talking to others online and sharing experiences will help.
Contact BCNA’s Helpline on 1800 500 258 between 9.00 am and 5.00 pm AEST Monday to Friday, for information about the services and support that may be available for you and your family.