Funder by the Department of Human Services Auspiced by Our Community

MAKING SENSE OF THE MEDICARE SAFETY NET AND THE PHARMACEUTICAL BENEFITS SCHEME


Medicare Safety Net

It's not easy to understand how the Medicare rebate and threshold system works.

Unfortunately, due to the sometimes frequent and often ongoing nature of some conditions associated with 'mental illness', not to mention the high fees charged by most private clinicians, consumers have a particular need to get their brains around these issues.

The basic concept is that poor people and people with chronic illness - that is, illness that goes on for a long time like some 'mental illnesses' - are protected by the structures of Medicare.

The second idea to note is that unless we are bulk billed (where payments from Medicare are managed automatically and are exactly equal what is charged by the clinician), we will have to pay money to doctors, with the amount we pay growing bigger and bigger the more often we see a doctor, or the more they charge.

The Federal Government's social justice policy suggests there should be cut off points within Medicare; a point at which "enough is enough" - these are called thresholds. When we reach a specific threshold (where we have paid out money up to a particular specified amount in a calendar year), the refunds provided by Medicare increase. Of course, we have to provide proof of this through production of receipts showing the fee for service we have paid or the 'gap' (anything we have paid beyond what Medicare will refund).

There are two of these trigger point thresholds - one for singles and one for families - and the threshold levels are significantly lower for people receiving Centrelink payments than for those who are not.

There is also a further complication of an Extended Safety Net Threshold, which is designed to alleviate the financial pressure on those with very high medical needs. This threshold jumps into gear at a lower level for pensioners than it does for all other Australians regardless of health status, prognosis or any other determining factor.

Medicare keeps careful records (including online records, which you can access over the internet) of what has been paid by you and what has been refunded. Medicare will contact you when you have reached either the first or the second threshold.

Keeping track

All of this can be extremely complex but it is vital that as consumers we understand how it all works. Too many people with a diagnosis of 'mental illness' are not receiving the refunds they deserve because they are confused about how it works or don't ask for the right records.

The easiest way to start keeping track of it all is to get a shoe box and be strict with yourself about collecting and putting in the box all receipts for all money you have paid out for all doctors.

The Medicare Safety Net scheme runs from January 1 to December 31. Around every three months during this period (or more regularly, or less regularly - but make sure you do it) take a trip to your closest Medicare office and take all your receipts with you. The officer there will be able to sort out what is refundable and what is not. Then clear the box and start again.

Refunds will be paid into a designated account (Medicare became cash free at the end of 2012).

All is not lost if you have mislay receipts. Medicare will be able to give you a reading telling you which ones are missing and your doctor will be able to reissue them.

Information on the Medicare system is available here.

Tax

You may be able to offset some of your medical expenses that have not been refunded against your income when you lodge your annual tax return - check with an accountant, a financial counselling service, or call the Australian Tax Office for clarification.


The Pharmaceutical Benefits Scheme & Safety Net

The Pharmaceutical Benefits Scheme (PBS) is an Australian-wide scheme that is designed to make medicines more accessible to all.

Apart from subsidising medicines, the scheme has responsibility for the PBS Safety Net, which is designed to kick in once an individual or family has reached a certain level (or threshold) of medication outlays in any calendar year.

After the safety net has been reached, most medications are free.

There are three different safety nets:

The safety net tally starts on January 1 each year and runs to December 31.

Each year the three different safety nets increase incrementally in accordance with the Consumer Price Index (CPI).

You can find the latest safety net levels here or call 1800 020 613 and ask to be sent a brochure.

Once you have reached your safety net threshold, your pharmacist can issue you with a safety net card. In order to do this the pharmacist will need to see your Medicare card, your prescription record form and your concession card (if appropriate).

On your PBS card you can include your spouse or de facto, family members under the age of 16 and dependent full-time students under the age of 25.

Keeping records

Records are important if you want to make the most of the PBS Safety Net.

Some pharmacies keep good records for you - this is a big incentive to always use the same pharmacy.

Pharmacies may also provide you with a card which you can take with you so that if you get scripts made up at another pharmacy the information is transferable to your own pharmacy. Note, though, that you don't have to have this card to get a script filled; just ask the pharmacist to record what they have prescribed to take back to your pharmacy.

It is advisable to also keep your own records. Things can go astray even with the best of systems in place. This will ensure you know as soon as you have reached the safety net threshold.

What to ask your doctor

Even with the PBS in place, medications can be expensive. Try to gather as much information as you can about what medications you're being prescribed. Ask your doctor:

What to ask your pharmacist

Your pharmacist can be a good ally in ensuring you're getting access to all your entitlements. Ask them:

Other things to note:

To find out more specific information about the PBS, go to www.health.gov.au/pbs or call 1800 020 613.

To read more about the PBS safety net go towww.medicareaustralia.gov.au/provider/pbs/pharmacists/safety-net.jsp

Some consumer criticisms of the PBS Safety Net

For many consumers, social and emotional resources are scarce. We may find relationships difficult and end up losing our community and living on our own. Unfortunately, the PBS Safety Net discriminates in favour of families, with thresholds being the same regardless of how many people are contributing towards them. This is not in the interest of many people with 'mental illness'.

Accurate record-keeping is also often quite difficult for some consumers, which can mean we struggle to keep track of where we are up to in reaching our safety net.

Another criticism of the PBS Safety Net is that no means test is applied. As mentioned elsewhere, many consumers work fewer hours, earn less money per hour and have chequered careers interrupted by episodes of 'illness' and recovery. Even if we are not on a disability support pension, we often earn less than the average wage - sometimes much less. Many of us can only cope with part-time work.

Medicines are extremely expensive and the jump from $4.80 per script for people with concession cards to the full price is enormous. This is a strong disincentive for us to try and get off the disability pension.