The Cost of Mental Health Support:

Navigating Medicare-supported appointments with Call to Mind

Medicare can help support the costs of seeing a medical specialist such as a psychiatrist. The level of support depends on the type of service you require and where you live. Also, to get Medicare support, you’ll need a referral from a GP.

If you live in a non-metropolitan area (Modified Monash Model (MMM) 2-6 inclusive), Call to Mind can provide a bulk-billed assessment by a psychiatrist (also known by the Medicare code “291”) as part of a comprehensive mental health review and treatment plan. Each “291” occurs at most once per year, and always requires a referral from a GP. If an additional review is required in six months, this is done through a new referral for an appointment with a different Medicare code (a “293”).

These psychiatric reviews are intended to support (and not to replace) your and your GP’s ongoing management of your mental health condition.

Case Study

Simone is a 35-year-old mother of two who developed postpartum depression following the birth of her second child. She saw a psychologist for 18 months, with only some improvement in her symptoms. Her GP recommended starting antidepressant medication. Unfortunately, Simone found that she was sensitive to the side effects of several antidepressant medications. So her GP recommended a referral to Call to Mind for a psychiatric assessment (291 appointment).

Simone was reviewed by a psychiatrist with a speciality in women’s mental health. In the review, the psychiatrist prescribed an alternative medication, as well as additional therapy and lifestyle modifications.

Simone saw some improvements with the new medication. However, given her history of side effects, Simone’s GP recommended a review of the management plan with her psychiatrist after three months to review the dosage. Simone continued to see improvements with her optimised medication dose, and now she continues to see her GP and new psychologist for ongoing follow-up appointments.

Out-of-pocket costs

If you live in a city/metropolitan area or if you require ongoing appointments, you can access Medicare-supported appointments with an out-of-pocket expense (usually $100 to $400, depending on the appointment type*). However, there are limits to the amount that you’ll be required to pay due to the Medicare Safety Net.

* Please note this is a guide only. For the latest information please visit the Medicare website or contact Medicare for specific information regarding your individual situation.

The Medicare Safety Net

You can read about the Medicare safety net here [4]. The Medicare Safety Net is designed to prevent you from paying too much in out-of-pocket medical expenses per year.

As part of the Safety Net, there is a rule about the “Greatest Permissible Gap” or GPG per appointment. Usually, you pay 15% of the total costs of an appointment (the “gap”), and Medicare covers 85% of it. But the GPG “kicks in” if 15% of the total cost of the appointment exceeds a certain amount – when that happens, you no longer have to pay 15%, and you just pay the “Greatest Permissible Gap” amount instead. You can look up what the current GPG is here. As of January 2024, it’s $98.70.

Example A: Suppose that there’s a medical service with a Schedule Fee of $700. This would mean that the default Medicare out-of-hospital rebate would be $595 (85% of the Schedule Fee) leaving a default gap of $105. Since that exceeds the greatest permissible gap, the maximum out-of-pocket costs would instead be set to $98.70, and Medicare would cover the rest (in this case, $601.3).

Example B: Simone was referred to a psychiatrist by her GP. (Please see the case study above.) The consultation type was classified as Item 291, which, as of January 2024, has the following costs:

· Medicare Benefits Schedule (MBS) Fee: $505.70

· Benefit: 85% of the Medicare Schedule Fee = 0.85*$505.70 = $429.85

· This would leave an out-of-pocket expense of $75.85 for Simone (but only if the psychiatry appointment cost exactly the MBS Fee – if it cost something different, the out-of-pocket expenses could change)

So if Simone was charged the MBS Fee for this appointment ($505.70), then her out-of-pocket expense ($75.85) would be less than the Greatest Permissible Gap (which is currently $98.70).

The final out-of-pocket amount that Simone would need to pay would depend on how much the psychiatrist charged for the appointment:

(i) If the psychiatrist charged $520, then Medicare would cover the benefit amount listed above ($429.85), leaving a default gap of $520 ─ $429.85 = $90.15. Since this does not exceed the GPG amount, Simone would pay the full default gap of $90.15.

(ii) If the psychiatrist charged $550, then Medicare would cover the benefit amount listed above ($429.85), leaving a default gap of $550 ─ $429.85 = $120.15. Since this is greater than the GPG amount, Simone would only pay the GPG amount of $98.70 (and the rest, $451.30, would be refunded by Medicare).

Example A: Suppose that there’s a particular service with a Schedule Fee of $100, and the out-of-hospital benefit is $85 (85% of the Schedule Fee). Also, suppose that the EMSN benefit cap is $30. Once someone reaches the EMSN threshold, the Medicare EMSN benefit/rebate will be the lower of the following: (a) 80% of the out-of-pocket costs and (b) the EMSN benefit cap for that item.

In this example, the out-of-hospital benefit is $85 (85% of the scheduled cost).

Suppose the actual fee charged for the service is $125. This leaves an initial out-of-pocket cost of $40, and 80% of this amount is $32. As the EMSN benefit cap is $30, $30 (rather than $32) of the out-of-pocket cost will be covered. In summary, Medicare covers $85 (the standard Medicare benefit) + $30 (the EMSN benefit), totalling $115.

Example B: Simone was referred to a psychiatrist by her GP. The consultation type was classified as Item 291. Earlier, we calculated the out-of-pocket expense for Simone based on the Greatest Permissible Gap.

In addition to the Greatest Permissible Gap, the Extended Medicare Safety Net Cap may change Simone’s out-of-pocket costs, but only if Simone has spent more than $2,414* in out-of-pocket medical expenses in a calendar year. (*Let’s assume Simone’s doesn’t have a concession card and doesn’t have a Family Tax Benefit Part A. If she did have either of those, on the other hand, the threshold would be $770.30 instead.)

For Item 291, the Extended Medicare Safety Net (EMSN) Cap is $500.00.

Let’s also assume Simone has already spent at least $2,414 in out-of-pocket medical expenses this year. In that case, when she has the Item 291 psychiatry appointment, the Medicare EMSN benefit/rebate will be the lower of the following: (a) 80% of the out-of-pocket costs and (b) the EMSN benefit cap for this item, which in this case is $500.00.

(i) Suppose that the psychiatrist charged $520. In that case, Medicare would cover the benefit amount listed above ($429.85), leaving a default gap of $520 ─ $429.85 = $90.15. This does not exceed the GPG amount, so the gap amount would stay at $90.15.

To determine the EMSN benefit, we now calculate , 80% of this out-of-pocket amount (gap), which is 0.8*$90.15 = $72.12. This is lower than the EMSN benefit cap of $500.00 for this item. Therefore, the EMSN benefit for Simone would be $72.12.

To calculate the final out-of-pocket total, we need to add both these amounts together. In this scenario, Medicare covers a total of $429.85 + $72.12 = $501.97, leaving a final total of $520 ─ $501.97 = $18.03 in out-of-pocket costs for Simone.

(ii) Suppose the psychiatrist charged $550. In that case, the standard Medicare benefit would cover the amount listed above ($429.85), leaving a default gap of $550 – $429.85 = $120.15. But since this is greater than the GPG amount (of $98.70), Simone would only have a gap of $98.70.

To determine the EMSN benefit, we now calculate 80% of the out-of-pocket amount (gap), which is 0.8*$98.70 = $78.96. This is lower than the EMSN benefit cap of $500.00 for this item. This means that the EMSN benefit for Simone would be $78.96.

To calculate the final out-of-pocket total, we need to add both these amounts together. In this scenario, Medicare covers a total of $429.85 + $78.96 = $501.97, leaving a final total of $550 – $508.81 = $41.19 in out-of-pocket costs for Simone.

What are the differences between psychologists and psychiatrists, and why might I need to see both?

For more information on this, please see our posts on psychiatrists and psychologists.

Are the costs of seeing a psychologist different?

The short answer is yes. For information about how to access Medicare funds to see a psychologist, please see this post by our psychology partner, Someone.health.

Face-to-face or telehealth: Is the rebate different?

The ease of access to a telehealth appointment can be helpful to people who work a busy schedule (because of the lack of a need to travel to a physical location) or to people who do not want their access to professional help to be limited by their physical location.

Medicare rebates are identical for face-to-face and telehealth therapy. In part, this is because research to date has shown that face-to-face and telehealth psychological therapy are equally effective. [1], [2], [3]

However, rebates are different for people who live in rural areas.

Online appointments help Call to Mind have greater reach in geographically isolated locations. Some people may choose to access telehealth due to being in a rural (non-metropolitan) area (Modified Monash Model (MMM) 2-6 inclusive), and higher Medicare rebates are available for these patients’ 291s as they are bulk-billed in these areas only.

Although the MBS fees and the standard scheduled Medicare rebates are the same for telehealth and face-to-face appointments, the amounts that clinics charge may differ for these two types of appointments. Face-to-face appointments will typically cost more due to the costs associated with running a face-to-face clinic.

Keeping track

It is essential that you maintain your own record of the number of sessions you attend so you do not exceed the available funds. If you would like to, or accidentally, go over the Medicare sessions available to you, then you pay privately. For example, the entitlement for 291 appointments is one per year. If a GP refers you for a 291 appointment, then you get another GP referral for another 291 appointment in the same year, the second appointment would incur the full cost without any rebate.

Are there other mental healthcare rebated services?

There are multiple types of mental-healthcare rebated services accessible under the Better Access Scheme. You might want to talk to your GP about this. For example, you might want to talk about the available benefits for:

Helping children with autism (under 13 years for a diagnostic assessment; under 15 years for treatment)
Supporting children with an eligible neurodevelopment disorder or eligible disability
Women concerned about a current or recent pregnancy
People living with a chronic medical condition
People of Aboriginal or Torres Strait Islander descent

The Cost of Mental Health Support:

Navigating Medicare-supported appointments with Call to Mind

References

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