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    Medicare benefits

    Medicare rebates will cover some of your treatment costs for macular disease.

    What can Medicare benefits can I claim for macular disease treatment?

    Medicare provides significant benefits (rebates) for many of the items related to eye injections and laser treatment. 

    The benefit is normally paid:

    • in ophthalmology rooms: as 85% of the schedule fee
    • in a private hospital or day case setting: as 75% of the schedule fee.

    Table One

    ItemDescriptionSchedule Fee85% benefit (in rooms)75% benefit (private hospital)
    104Initial consultation$89.55$76.15$67.20
    105Subsequent consultation$45.00$38.25$33.75
    11215Angiogram (one eye)$126.80$107.80$95.10
    11218Angiogram (two eyes)$156.70$133.20$117.55
    11219Optical coherence tomography (OCT)
    (initial diagnosis only)
    $41.25$35.10$30.95
    42738Injection fee$310.15$263.65$232.65
    42739Injection with sedation / anaesthetic$310.15$263.65$232.65
    42809Retina photocoagulation (laser)$458.30$389.60$343.75

    Notes:

    • From 1 Nov 2017, item 105 cannot be used (that is, there is no Medicare rebate) if you are also receiving a procedure (such as an eye injection or laser) on the same day. 
    • For injections in both eyes on the same day, the benefit for the second eye is reduced by 50%. 
    • If two eyes are treated on separate days, the normal benefits apply. 
    • OCT scans will only be reimbursed for an initial diagnosis to confirm eligibility for PBS-funded eye injections, with a maximum of one reimbursement per year.

    Original Medicare Safety Net

    The difference between the schedule fee and the benefit paid by Medicare is known as the gap amount. 

    The gap amount for an eye injection given in the ophthalmologists’ rooms is currently $46.50. 

    This is calculated as the schedule fee ($310.15) minus Medicare benefit ($263.65). (Refer to Table One) 

    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. 

    For example, for item 42738 (Injection fee), you would receive a benefit of $263.65. 

    The Original Medicare Safety Net threshold is set by the Australian Government and changes from time to time. 

    In 2020, the Original Medicare Safety Net threshold is $477.90.

    Out-of-pocket costs

    Ophthalmologists may charge more than the Medicare schedule fee. The difference between the ophthalmologist fee and the Medicare benefit is the out-of-pocket (OOP) cost. This is different to then gap amount, which is the difference between the scheduled fee and the benefit. 

    As an example, if an ophthalmologist charges $400 for an in-rooms injection (Medicare item 42738), the scheduled fee is $310.15, but you receive a benefit of $263.65. Therefore the out-of-pocket cost is $136.35. This is perhaps best seen in table format, below. (Note: Costs do vary between ophthalmologists. This is an example only.)

    Table Two

    ServiceItemOphthal’s fee (a)Medicare schedule (b)Medicare benefit (c) i.e 85% of (b)OOP cost per vision ie (a) minus (c)
    Injection 42738$400$210.15$263.65$136.35

    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. 

    Rebate caps do apply. The Extended Medicare Safety Net threshold is set by the Australian Government and changes from time to time. 

    In 2021, the threshold for out-of-pocket costs are $692.20 for concession card holders, and $2,169.20 for non concession.

    To provide an example using the same Medicare item used above – the injection, item 42738 – in Table Two. 

    Before the Extended Medicare Safety Net threshold is reached, you’ll remember the ophthalmologist charged $400, and your out-of-pocket cost was $136.35. With the Extended Medicare Safety Net, you’ll get the normal Medicare benefit of $263.65, plus the EMSN benefit of $109.08 (being 80 per cent of the OOP amount of $136.35). That gives a total benefit of $372.73. This means you pay only $27.27 after receiving all the rebates. 

    Here it is again, explained in a table.

    Table Three

    ServiceTotal charged (a)Medicare benefit (b)OOP costs before EMSN threshold (c) i.e. (a) minus (b)EMSN benefit (d)OOP costs after EMSN threshold i.e. (a) minus (b) minus (d)
    Injection 
    Item 42738
    $400$263.65$136.35$109.08$27.27 (20% of OOP)

    Capped benefits

    For some procedures, including eye injections, Extended Medicare Safety Net benefits are capped.

    For items 42738 and 42739, which are the injection fees without and with sedation, the EMSN benefit is capped at  $244.45.

    The maximum rebate you can receive after reaching only the Extended Medicare Safety Net threshold is $504.20. The maximum rebate you can receive after reaching both the Original and Extended Medicare Safety Net thresholds, is $550.

    It should be noted that other than when used for an initial diagnosis to confirm eligibility for PBS-funded injections, OCT scans do not attract any Medicare benefits. That means they don’t contribute towards either the Original or Extended Medicare Safety Net threshold.

    It’s also worth noting that procedures performed in a private hospital or day surgery setting don’t contribute towards the Original or Extended Medicare Safety Net threshold either and don’t receive the additional benefits.

    Registering for the Medicare Safety Net

    If you are part of a couple or a family, you need to register as a Medicare Safety Net family, even if you are all listed on the same Medicare card.

    Medicare will automatically keep a total of your gap amounts and out-of-pocket medical expenses. 

    Registration is free and you only need to register once in your lifetime. 

    To register for the Medicare Safety Net, complete the Medicare Safety Net Registration and Amendment for Couples and Families form. You can also do this in person at your nearest Medicare service centre, or by calling 132 011.

    Download our fact sheet

    If you’d like to keep this information handy, we suggest you download our Eye injection costs and rebates fact sheet. You can also order a free hard copy of this fact sheet and we’d send it to you by post.

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    Eye injection costs and rebates

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