What 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 per cent of the schedule fee
- in a private hospital or day case setting: as 75 per cent of the schedule fee.
Table One
| Item | Description | Schedule Fee | 85% benefit (in rooms) | 75% benefit (private hospital) |
|---|---|---|---|---|
| 104 | Initial consultation | $95.60 | $81.30 | $71.70 |
| 105 | Subsequent consultation | $48.05 | $40.85 | $36.05 |
| 11215 | Angiogram (one eye) | $135.35 | $115.05 | $101.55 |
| 11218 | Angiogram (two eyes) | $167.30 | $142.25 | $125.50 |
| 11219 | Optical coherence tomography (OCT) (initial diagnosis only) | $43.95 | $37.40 | $33 |
| 42738 | Injection fee | $331.05 | $281.40 | $248.30 |
| 42739 | Injection with sedation / anaesthetic | $331.05 | $281.40 | $248.30 |
| 42809 | Retina photocoagulation (laser) | $496.45 | $422 | $372.35 |
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 per cent.
- 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 $49.65.
This is calculated as the schedule fee ($331.05) minus the 85 per cent Medicare benefit ($281.40) (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 per cent of the schedule fee for subsequent non-hospital Medicare items. For example, for item 42738 (Injection fee), you would receive the full benefit of $331.05.
The Original Medicare Safety Net threshold is set by the Australian Government and changes from time to time.
In 2024, the Original Medicare Safety Net threshold is $560.40.
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 the gap amount, which is the difference between the scheduled fee and the benefit.
As an example, if an ophthalmologist charges $500 for an in-rooms injection (Medicare item 42738), the scheduled fee is $331.05, but you receive an 85 per cent benefit of $281.40. Therefore the out-of-pocket cost is $218.60. This is detailed in Table Two below. (Note: Costs do vary between ophthalmologists. This is an example only.)
Table Two
| Service | Item | Ophthal’s fee (a) | Medicare schedule (b) | Medicare benefit (c) i.e 85% of (b) | OOP cost per vision ie (a) minus (c) |
|---|---|---|---|---|---|
| Injection | 42738 | $500 | $331.05 | $281.40 | $218.60 |
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 2024, the threshold for out-of-pocket costs are $811.80 for concession card holders, and $2,544.30 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 $500, and your out-of-pocket cost was $218.60. With the Extended Medicare Safety Net, you’ll get the normal Medicare benefit of $281.40, plus the EMSN benefit of $174.88 (being 80 per cent of the OOP amount of $218.60). That gives a total benefit of $456.28. This means you pay only $43.72 after receiving all the rebates.
This is detailed in Table Three.
Table Three
| Service | Total 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 | $500 | $281.40 | $218.60 | $174.88 | $43.72 (20% of OOP) |
Out-of-pocket costs excluded from the Medicare Safety Net
For some procedures, including eye injections, the Extended Medicare Safety Net benefits are capped. That means any out-of-pocket costs above the capped amount will not contribute towards reaching the Extended Medicare Safety Net threshold.
Other than when used for an initial diagnosis to confirm eligibility for PBS-funded injections, OCT scans do not attract any Medicare benefits. This means they do not contribute towards reaching the Original or Extended Medicare Safety Net thresholds.
Procedures performed in a private hospital or day surgery setting do not contribute towards reaching the Original or Extended Medicare Safety Net thresholds.
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.
Get the fact sheet
This information is available in a handy fact sheet. You can view it below, or head to our resources section and we’ll send you a hard copy version. All our resources are free.
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