{"id":"F2017L01082","name":"Health Insurance (Extended Medicare Safety Net) Determination 2017","slug":"health-insurance-extended-medicare-safety-net-determination-2017","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":96993,"registerId":"commonwealth-F2017L01082-current","compilationNumber":null,"startDate":"2026-04-02","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"part","heading":"Name of Determination","content":"# 1 Name of Determination\n\nThis Determination is the Health Insurance (Extended Medicare Safety Net) Determination 2017.","sortOrder":0},{"sectionNumber":"3","sectionType":"part","heading":"Definitions","content":"# 3 Definitions\n\nIn this Determination:\n\nAct means the Health Insurance Act 1973.\n\ndiagnostic imaging services table means the table prescribed under section 4AA of the Act.\n\ngeneral medical services table means the table prescribed under section 4 of the Act.\n\n> Schedule fee has the meaning given in subsection 8 (1A) of the Act.","sortOrder":1},{"sectionNumber":"4. Maximum increases for items under sec","sectionType":"part","heading":"4. Maximum increases for items under sections 10ACA and 10ADA of the Act","content":"# 4. Maximum increases for items under sections 10ACA and 10ADA of the Act\n\n(1) For section 10B of the Act:\n\n(a) subsections 10ACA(7A) and 10ADA(8A) apply to the items of the general medical services table, and items in a determination made under subsection 3C(1) of the Act, listed in column 1 of the table below; and\n\n(b) the maximum increases for these items are listed in column 2.\n\n| Item  | Maximum increase ($)                         |\n| ----- | -------------------------------------------- |\n| 13200 | 2118.30                                      |\n| 13201 | 3074.90                                      |\n| 13202 | 81.90                                        |\n| 13203 | 136.50                                       |\n| 13209 | 13.60                                        |\n| 13212 | 88.70                                        |\n| 13215 | 61.40                                        |\n| 13218 | 888.30                                       |\n| 13221 | 27.30                                        |\n| 13251 | 136.50                                       |\n| 13260 | 65 percent of the Schedule fee for the item  |\n| 14201 | 15 percent of the Schedule fee for the item  |\n| 14202 | 15 percent of the Schedule fee for the item  |\n| 14216 | 617.70                                       |\n| 14217 | 391.10                                       |\n| 14219 | 617.70                                       |\n| 14220 | 391.10                                       |\n| 16400 | 13.80                                        |\n| 16401 | 69.30                                        |\n| 16404 | 41.40                                        |\n| 16406 | 136.50                                       |\n| 16407 | 65 percent of the Schedule fee for the item  |\n| 16408 | 65 percent of the Schedule fee for the item  |\n| 16500 | 41.40                                        |\n| 16501 | 83.00                                        |\n| 16502 | 27.60                                        |\n| 16505 | 27.60                                        |\n| 16508 | 27.60                                        |\n| 16509 | 27.60                                        |\n| 16511 | 138.40                                       |\n| 16512 | 41.40                                        |\n| 16514 | 20.70                                        |\n| 16515 | 221.80                                       |\n| 16518 | 221.80                                       |\n| 16519 | 415.80                                       |\n| 16527 | 221.80                                       |\n| 16530 | 65 percent of the Schedule fee for the item  |\n| 16567 | 277.20                                       |\n| 16570 | 277.20                                       |\n| 16571 | 277.20                                       |\n| 16590 | 277.20                                       |\n| 16591 | 138.40                                       |\n| 16600 | 41.40                                        |\n| 16603 | 83.00                                        |\n| 16606 | 166.30                                       |\n| 16609 | 319.00                                       |\n| 16618 | 131.60                                       |\n| 32500 | 110 percent of the Schedule fee for the item |\n| 32520 | 15 percent of the Schedule fee for the item  |\n| 32522 | 10 percent of the Schedule fee for the item  |\n| 32523 | 15 percent of the Schedule fee for the item  |\n| 32526 | 10 percent of the Schedule fee for the item  |\n| 32528 | 15 percent of the Schedule fee for the item  |\n| 32529 | 10 percent of the Schedule fee for the item  |\n| 42505 | 15 percent of the Schedule fee for the item  |\n| 45560 | 35 percent of the Schedule fee for the item  |\n| 82100 | 27.30                                        |\n| 82105 | 20.40                                        |\n| 82110 | 27.30                                        |\n| 82115 | 68.20                                        |\n| 82130 | 20.40                                        |\n| 82135 | 27.30                                        |\n| 82140 | 20.40                                        |\n| 91850 | 13.80                                        |\n| 91851 | 65 percent of the Schedule fee for the item  |\n| 91852 | 65 percent of the Schedule fee for the item  |\n| 91853 | 41.40                                        |\n| 91855 | 13.80                                        |\n| 91856 | 65 percent of the Schedule fee for the item  |\n| 91857 | 65 percent of the Schedule fee for the item  |\n| 91858 | 41.40                                        |\n\n(2) For section 10B of the Act:\n\n(a) subsections 10ACA(7A) and 10ADA(8A) apply to items 11602, 11604, 11607, 11610, 18270, 18272, 30216, 30219, 14100, 30071, 31560, 32504, 34106, 42590, 43030, 43032, 43034, 43036, 43038, 43040, 45003, 45025, 45026, 45200, 45203, 45206, 45545, 45614, 45617, 45620, 45623, 45624 and 45652 of the general medical services table; and\n\n(b) the maximum increase for each item is 80 percent of the Schedule fee for that item.\n\n(3) For section 10B of the Act:\n\n(a) subsections 10ACA(7A) and 10ADA(8A) apply to each item in the Group of the general medical services table, and items in a determination made under subsection 3C(1) of the Act relating to services within those Groups, listed in the column of the table below; and\n\n(b) the maximum increase for each item is 300 percent of the Schedule fee for that item or $500.00 for that item whichever represents the lesser amount.\n\n| Group |\n| ----- |\n| A1    |\n| A2    |\n| A3    |\n| A4    |\n| A5    |\n| A6    |\n| A7    |\n| A9    |\n| A10   |\n| A11   |\n| A12   |\n| A13   |\n| A14   |\n| A17   |\n| A18   |\n| A19   |\n| A20   |\n| A21   |\n| A22   |\n| A23   |\n| A24   |\n| A26   |\n| A27   |\n| A28   |\n| A29   |\n| A30   |\n| A31   |\n| A32   |\n| A33   |\n| A35   |\n| A36   |\n| A39   |\n| A40   |\n| A41   |\n| A42   |\n| A45   |\n| A46   |\n| T6    |\n\n(3A) For section 10B of the Act:\n\n(a) subsections 10ACA(7A) and 10ADA(8A) apply to all items in Group A8 (except item 297) in a determination made under subsection 3C(1) of the Act; and\n\n(b) the maximum increase for each item is 300 percent of the Schedule fee for that item or $500.00 for that item whichever represents the lesser amount.\n\n(3B) For section 10B of the Act:\n\n(a) subsections 10ACA(7A) and 10ADA(8A) apply to all items in Group A15 (except item 880) in a determination made under subsection 3C(1) of the Act; and\n\n(b) the maximum increase for each item is 300 percent of the Schedule fee for that item or $500.00 for that item whichever represents the lesser amount.\n\n(4) For section 10B of the Act:\n\n(a) subsections 10ACA(7A) and 10ADA(8A) apply to each item in the Group of the general medical services table, and items in a determination made under subsection 3C(1) of the Act relating to services within those Groups, listed in the column of the table below; and\n\n(b) the maximum increase for each item is 300 percent of the Schedule fee for that item or $500.00 for that item whichever represents the lesser amount.\n\n| Group |\n| ----- |\n| M3    |\n| M6    |\n| M7    |\n| M8    |\n| M9    |\n| M10   |\n| M11   |\n| M12   |\n| M14   |\n| M15   |\n| M16   |\n| M17   |\n| M18   |\n| M19   |\n| M25   |\n| M26   |\n| M27   |\n| M28   |\n| M32   |\n| O1    |\n\n(5) For section 10B of the Act:\n\n(a) subsections 10ACA(7A) and 10ADA(8A) apply to item 13899 of the general medical services table and items 75002, 75005, 75150, 75153, 82150, 82151, 82152, 90183, 90188, 90202 and 90212 in a determination made under subsection 3C(1) of the Act; and\n\n(b) the maximum increase for each item is 300 percent of the Schedule fee for that item or $500.00 for that item whichever represents the lesser amount.\n\n(6) For section 10B of the Act:\n\n(a) subsections 10ACA(7A) and 10ADA(8A) apply to the items of the diagnostic imaging services table, and items in a determination made under subsection 3C(1) of the Act, listed in column 1 of the table below; and\n\n(b) the maximum increases for these items are listed in column 2.\n\n| Item  | Maximum increase ($)                        |\n| ----- | ------------------------------------------- |\n| 11704 | 80 percent of the Schedule fee for the item |\n| 55054 | 80 percent of the Schedule fee for the item |\n| 55238 | 80 percent of the Schedule fee for the item |\n| 55244 | 80 percent of the Schedule fee for the item |\n| 55246 | 80 percent of the Schedule fee for the item |\n| 55252 | 80 percent of the Schedule fee for the item |\n| 55276 | 80 percent of the Schedule fee for the item |\n| 55296 | 80 percent of the Schedule fee for the item |\n| 55700 | 40.70                                       |\n| 55703 | 20.40                                       |\n| 55704 | 47.70                                       |\n| 55705 | 20.40                                       |\n| 55706 | 68.20                                       |\n| 55707 | 47.70                                       |\n| 55708 | 20.40                                       |\n| 55709 | 27.20                                       |\n| 55712 | 81.80                                       |\n| 55715 | 27.20                                       |\n| 55718 | 68.20                                       |\n| 55721 | 81.80                                       |\n| 55723 | 27.20                                       |\n| 55725 | 27.20                                       |\n| 55729 | 20.40                                       |\n| 55740 | 71.00                                       |\n| 55741 | 30.50                                       |\n| 55742 | 71.00                                       |\n| 55743 | 30.50                                       |\n| 55757 | 33.70                                       |\n| 55758 | 10.90                                       |\n| 55762 | 40.70                                       |\n| 55764 | 109.00                                      |\n| 55766 | 40.70                                       |\n| 55768 | 102.40                                      |\n| 55770 | 40.70                                       |\n| 55772 | 109.00                                      |\n| 55774 | 47.70                                       |","sortOrder":2}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"},"flash_summary":{"complexity_score":6,"scope_assessment":{"changed":false,"description":"This Determination updates and specifies monetary caps that operate within the pre-existing EMSN framework in the Health Insurance Act. It does not alter the statutory scope of who may receive EMSN or create new categories of entitlement; it narrows or bounds the monetary amounts that are recognisable for particular items but remains within the original purpose of setting maximum increases for EMSN calculation. In other words, it is a technical/administrative change (item- and group-specific caps) rather than an expansion of the legislation's substantive scope."},"complexity_factors":["Cross-references to multiple sections and subsections of the Health Insurance Act (notably 10B, 10ACA(7A), 10ADA(8A), 3C(1) and subsection 8(1A)).","Three distinct application streams: (a) individually listed general medical service items with fixed dollar or percentage caps (clause 4(1)); (b) lists of individual items with a uniform 80% rule (clause 4(2)) or group-wide 300%/ $500 rule (clauses 4(3)–4(5)); (c) separately listed diagnostic imaging items (clause 4(6)).","Mixed cap types: fixed dollar amounts, percentages of the Schedule fee, and conditional rules using \"whichever represents the lesser amount\" (e.g. 300% of Schedule fee or $500) — these require different arithmetic per item.","Numerous item-specific entries: the Determination enumerates approximately 150–180 specific item numbers across the general medical and diagnostic imaging tables (presented as multiple long tables).","Multiple group codes: the Determination lists roughly 50–70 group codes (A1–A46 variants, M groups, O1, T6, etc.) to which a single cap rule applies.","Exceptions inside group rules: for example, Group A8 (except item 297) and Group A15 (except item 880) — adds nested conditionality.","Dependence on external definitions and variable values: the \"Schedule fee\" is defined and updated elsewhere in the Health Insurance Act/Medicare Schedule, so the monetary effect varies over time without amending this Determination.","Administrative burden: applying different caps per item/group increases processing complexity for claim assessment and for providers advising patients on EMSN entitlements."],"plain_english_summary":"**What this Determination does (mechanics)\n\n- This instrument sets the maximum amounts that the Extended Medicare Safety Net (EMSN) will recognise for particular Medicare services. Practically, it tells Medicare how large an \"increase\" above the Schedule fee can be taken into account for certain item numbers or groups of items when calculating additional EMSN rebates. (The \"Schedule fee\" is the basic fee for a Medicare item set under the Health Insurance Act.)\n\n- It does this by listing specific Medicare item numbers and groups, and prescribing for each either: a fixed dollar cap, a percentage of the Schedule fee, or a rule that uses whichever of two amounts is the smaller (for example, 300% of the Schedule fee or $500, whichever is lesser). The Determination applies its caps by reference to the Health Insurance Act sections that govern the EMSN (notably subsections 10ACA(7A), 10ADA(8A) and section 10B). See key clauses: (1), (2), (3)–(5) and (6).\n\n- The Determination covers items in two different Schedule tables: the general medical services table and the diagnostic imaging services table, and also applies to items listed in any determination made under subsection 3C(1) of the Health Insurance Act. It includes several group-wide rules (Groups A1, A2, …, M3, M6, etc.) as well as many individually listed item numbers.\n\nWho is affected\n\n- Patients who qualify for the Extended Medicare Safety Net (EMSN) and receive the listed services: the cap determines how much of their out‑of‑pocket cost will be recognised for extra EMSN subsidy.\n\n- Medical service providers (doctors, specialists, imaging providers, etc.): the caps constrain how much of a practitioner's extra charge above the Schedule fee will count towards the patient’s EMSN threshold or rebate calculation for the listed items.\n\n- Medicare/Services Australia administrators: they must apply these item‑ and group‑specific caps when calculating EMSN entitlements and process claims accordingly.\n\nWhy it matters (official purpose and practical implications)\n\n- Officially, this is a technical instrument to limit the extent to which large provider fees for particular services increase the EMSN liability. The Determination implements monetary limits (fixed dollar or percentage of Schedule fee) so the extra Safety Net rebate is bounded for the listed items (clauses (1)–(6)).\n\n- Practical effects and trade-offs:\n  - Who pays: by capping what counts for EMSN rebates, the Determination limits the amount the government (taxpayers) may reimburse through EMSN for those items. That reduces the potential EMSN subsidy per service for patients who face high provider charges on the listed items (see clause (1), (2), (6)).\n  - Who decides/prices: providers retain freedom to set their fees, but these caps constrain how much of any increased fee will be recognised under EMSN. Providers may therefore face stronger incentives to justify higher fees or to shift charges to other items not capped by this Determination (see clauses (3), (4), (3A), (3B)).\n  - Compliance and administrative cost: the measure is item‑specific and uses mixed rules (fixed dollars, percentages, or lesser‑of rules). That raises processing complexity for Medicare claim assessment and for providers calculating what will be recognised for EMSN (see multiple tables and cross‑references to the Act).\n  - Incentives and substitution effects: because some items have strict caps (fixed dollar limits or low percentages) while others are less constrained, providers and patients could shift service provision, claim coding, or billing strategies toward items not listed or less tightly capped. The Determination does not change the underlying entitlement rules in the Act — it only sets the monetary bounds that apply to the listed services (see cross‑references to subsections 10ACA(7A) and 10ADA(8A)).\n\nImplementation details to note\n\n- The Determination is highly granular: it lists many individual Medicare item numbers with explicit dollar caps or percentage caps (clauses (1) and (6)); it also applies caps across named Groups of items with a common rule (clauses (3), (3A), (3B), (4)).\n\n- Some rules are conditional: e.g. \"300% of the Schedule fee or $500, whichever is the lesser\"; other caps are fixed dollar amounts; others are percentages of the Schedule fee (clauses (3), (4), (6)).\n\n- The Determination relies on defined terms and on Schedule fees set elsewhere in the Health Insurance Act framework (see Definitions, clause 3: definition of Act, diagnostic imaging services table, general medical services table and reference to \"Schedule fee\" under subsection 8(1A) of the Act).\n\nKey source clauses: Definitions and application mechanics are in clause 3; item and group caps are in clauses 4(1)–4(6) (presented as tables and group lists)."},"kimi_summary":{"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"The legislation appears to be performing its intended narrow function: setting specific benefit caps for the Extended Medicare Safety Net. It does not appear to have expanded beyond its original purpose of limiting EMSN benefits for specific medical services."},"complexity_factors":["Multiple calculation methods: mixes fixed dollar amounts, percentages of Schedule fees, and 'whichever is lesser' formulas (300% or $500)","Cross-references to primary legislation: relies on definitions and sections from the Health Insurance Act 1973 (sections 4, 4AA, 10B, 10ACA, 10ADA, 3C)","Extensive item-by-item specification: 60+ individual item numbers with specific caps in subsection (1), plus 30+ items in subsection (2)","Group-based classifications: references 37 different Groups (A1-A46, T6, M3-M32, O1) requiring knowledge of the General Medical Services Table structure","Exception-within-exception structure: subsections (3A) and (3B) apply caps to entire Groups but explicitly exclude specific items (297 and 880)","Dual table application: applies to both the General Medical Services Table and the Diagnostic Imaging Services Table"],"plain_english_summary":"This Determination sets dollar amounts and percentage caps that limit how much extra Medicare will pay under Australia’s Extended Medicare Safety Net (EMSN) for specific medical services. By listing itemised caps—either fixed sums or percentages of the Schedule fee—it affects patients who reach the EMSN threshold, the doctors who bill those services, and government spending. The caps restrain taxpayer exposure and reduce incentives for fee inflation."}},"importantCases":[],"_links":{"self":"/api/acts/health-insurance-extended-medicare-safety-net-determination-2017","history":"/api/acts/health-insurance-extended-medicare-safety-net-determination-2017/history","analysis":"/api/acts/health-insurance-extended-medicare-safety-net-determination-2017/analysis","conflicts":"/api/acts/health-insurance-extended-medicare-safety-net-determination-2017/conflicts","importantCases":"/api/acts/health-insurance-extended-medicare-safety-net-determination-2017/important-cases","documents":"/api/acts/health-insurance-extended-medicare-safety-net-determination-2017/documents"}}