Medicare Safety Net Thresholds
Medicare Safety Net thresholds as at January 2008
| Threshold | Who it is for? | How it is calculated? | Benefit to you | |
|---|---|---|---|---|
| Concession and Family Tax Benefit (Part A) {FTB(A)} | $529.30* | Commonwealth concession card holders Families eligible for FTB(A) |
Out-of-pocket costs | 80% of out-of-pocket costs for out-of-hospital services |
| Gap | $365.70* | All Medicare card holders | Based on gap amount | 100% of Schedule fee for out-of-hospital services |
| General | $1058.70* | All Medicare card holders | Out-of-pocket costs | 80% of out-of-pocket costs for out-of-hospital services |
* These amounts are adjusted annually.
Out-of-pocket costs —the difference between the Medicare benefit and what your doctor charges you.
Gap amount —the difference between the Medicare benefit and the Schedule fee.
Schedule fee —a fee for service set by the Australian Government.
Remember: You need to give Medicare all of your receipts for doctor's accounts. This way you can make sure you get all the benefits that you're entitled to
Is it possible to reach more than one threshold?
Yes—it is possible to reach more than one threshold in a calendar year. Medicare will calculate the benefits you are entitled to and when you reach another threshold, following confirmation of your family make-up (for registered families only), you will be automatically paid the higher benefit for claims made on fully paid accounts for the rest of that calendar year.
General threshold
Who is the general threshold for?
The general threshold is for all Medicare card holders.
How is the threshold calculated?
This threshold is reached by calculating your out-of-pocket medical costs. Out-of-pocket costs are the difference between the Medicare benefit and what your doctor charges you.
Remember: You need to give Medicare all of your receipts for doctor's accounts. This way you can make sure you get all the benefits that you're entitled to.
What am I entitled to once the general safety net threshold is met?
Medicare will refund the Medicare benefit plus 80 per cent of the difference between the Medicare benefit and your doctor's charge.
- When you pay the account in full, you will receive the Medicare plus the 80 percent rebate.
- When you do not pay the account in full you will be issued with a cheque to give to your doctor for the Medicare benefit . Once you pay the remainder of the account in full and you provide proof of payment to Medicare (that is your receipt), the additional 80 per cent benefit is then paid to you.
For example, if you reach and qualify for the general threshold and then visit your GP who charges $55, you will receive your Medicare benefit of $31.45. You will also receive 80 per cent of your out-of-pocket costs giving you an extra $18.85 in your pocket. So it will effectively only cost you $4.70 to go to your GP.
Gap threshold
Who is the gap threshold for?
The gap threshold is for all Medicare card holders.
How is the gap threshold calculated?
This threshold is reached by calculating your gap amounts. Medicare usually pays 85 per cent of the Medicare Schedule fee when you visit a doctor other than your GP.
The Schedule fee is the fee for service set by the Australian Government—not the fee charged by the doctor.
Remember: You need to give Medicare all of your receipts for doctor's accounts. This way you can make sure you get all the benefits that you're entitled to.
What am I entitled to once the gap safety net threshold is met?
Medicare will will refund you 100 per cent of the Schedule fee.
- When you pay the account in full you will receive the 100 per cent of the Schedule fee.
- When you do not pay the account in full you will be be issued with a cheque to give to your doctor for 100 per cent of the Schedule fee which you take to the doctor along with any outstanding balance.
Who is the concession and FTB(A) threshold for?
Eligible concession cards are those issued by either Centrelink or the Department of Veterans’ Affairs, including:
- pensioner cards
- health care cards
- Commonwealth seniors’ health cards
Who is considered a concessional family?
A concessional family is a combination of at least one adult plus another family member who is entitled to a Commonwealth concession card. Only these concession card holders’ out-of-pocket costs count toward the concession Medicare Safety Net threshold.
If one or more children within your family have concession cards but you and your spouse do not, then your child/children are treated as individuals for the purposes of calculations and payments under this safety net.
Who is considered an FTB(A) family?
If you are eligible for an FTB(A) payment you and your family are eligible for the FTB(A) Medicare Safety Net threshold.
There are two ways families can claim an FTB(A) payment as a fortnightly instalment or as a lump sum payment.
Fortnightly instalment examples
- if you claim FTB(A) as a fortnightly instalment via the Family Assistance Office your FTB(A) safety net threshold eligibility will commence from the date of payment in that calendar year
- if you claim FTB(A) by deferring your fortnightly instalment payments through the Family Assistance Office your FTB(A) safety net threshold eligibility will commence from the date of deferment in that calendar year.
Lump sum examples
- if you claim FTB(A) as a lump sum payment through the Family Assistance Office for a past period, ie the previous financial year your FTB(A) safety net threshold eligibility will commence the following calendar year
- if you claim FTB(A) as a lump sum payment through the Tax Office your FTB(A) safety net eligibility will commence the following calendar year
- if you claim FTB(A) as a fortnightly tax deduction through the Tax Office your FTB(A) your FTB(A) safety net eligibility will commence the following calendar year.
Please note: Lump sum payments must be received before 31 December to be eligible for the next entire calendar year. If the payment is made after 31 December, eligibility will commence from the date of payment in the eligible calendar year in which it is received.
Disclaimer: How you choose to receive your FTB(A) payment/s determines your eligibility for the FTB(A) safety net threshold. It is your responsibility to understand that your choice of FTB(A) payment can affect your perceived FTB(A) safety net threshold eligibility.
For more information on FTB(A)
- call the Family Assistance office on 136 150
- call the Tax Office on 132 861
- visit your local Medicare office, Centrelink Customer service centre or ATO shopfront.
What if I'm only a concession card holder for part of the year or receive only one FTB(A) payment?
If you are a concession card holder or you are eligible for FTB(A) at any time during a calendar year, you are eligible for the concession and FTB(A) Medicare Safety Net threshold for the remainder of that year starting from the concessional eligibility date.
If you claim your FTB(A) through your tax return you would be eligible for the safety net in the following calendar year.
Last updated: 28 May, 2008