Medicare Items for Complex and Chronic Conditions
Chronic Disease Management Items
-previously the Enhanced Primary Care (EPC) Program
Information for clients and family or carers
- GP assesses client’s eligibility for Chronic Disease Management Medicare items (known as EPC) plan and makes referral to speech pathologist
- Client (or the client’s parent) requests a referral to a known speech pathologist or the GP recommends one
- Client must have an EPC plan before they can claim a rebate from Medicare
- Up to maximum of five sessions can be claimed per calendar year
- The five sessions may be with one health professional or a number of allied health professionals
- Client claims rebate using invoice provided by speech pathologist
Who is eligible for an EPC plan?
Clients who have a chronic condition and complex care needs that are being managed by their GP under an Enhanced Primary Care (EPC) plan may be eligible.
A chronic condition is one that has been present for six months or longer. Clients have complex care needs if they need ongoing care from a multidisciplinary team consisting of their GP and at least two other health care providers, one of which may be a speech pathologist.
Residents of aged care facilities may also be eligible for this program.
Hospital in-patients are not eligible for the EPC program.
If you are unsure as to you (or your child’s) eligibility please discuss with your GP.
Who makes the referral to the speech pathologist?
The GP will prepare a GP Management Plan and Team Care Arrangements and make the referral to the speech pathologist using an EPC referral form. The client cannot claim the rebate from Medicare until the speech pathologist receives the referral form
The client may request to see a particular speech pathologist or the GP may recommend one.
The speech pathologist must be registered with Medicare. (If the speech pathologist is registered with Medicare they will have a provider number.)
What does the client receive?
The GP nominates the number of sessions up to a maximum of 5 per calendar year.
The five sessions are per client, not five sessions per allied health professional, and may be with a number of allied health professionals (e.g., three with a speech pathologist and two with an occupational therapist).
If all sessions are not used during the calendar year in which the client was referred, the unused sessions can be used in the next calendar year. However, those sessions will be counted as part of the five sessions with allied health professionals available to the client during that calendar year.
Clients continue to be eligible for rebates for speech pathology while they are being managed under an EPC plan as long as the need for eligible services continues to be recommended, by their GP, in their plan.
What is a session?
A session is a consultation with an allied health professional. The consultation must be of at least 20 minutes duration and must be provided to an individual client. The speech pathologist named on the referral form should provide the service. If there is a change in the speech pathologist providing the service the GP should be notified of the change.
How much is the rebate?
The rebate is currently $50.05 (as at February 2010)
Medicare rebates are indexed on 1 November each year.
Please note: the speech pathologist is able to set the level of their fee. In most cases the fee will be more than the rebate. The client pays the full fee and then claims the rebate from Medicare. The out-of-pocket expense will count towards the Medicare safety net.
Claiming a rebate
Upon payment of the fee the speech pathologist provides the client with a receipt.
The receipt must include;
Date of service
MBS item number (Speech Pathology item number = 10970)
Speech pathologist’s name and provider number
Referring GP’s name and provider number
Date of referral
Total amount paid
Any amount outstanding in relation to the service
The rebate will be paid when this receipt is presented to Medicare.
If the client loses track of how may speech pathology services they have claimed in a calendar year they can contact Medicare on 132 011.
What happens if the client has private health insurance?
The client may not claim a Medicare rebate and a private health insurance rebate for the same service. The client must choose which rebate they are going to claim for a service.
Other allied health professionals who provide services under the EPC program?
There are a range of other allied health professionals, in addition to speech pathologists, who can provide services under the EPC program. These include;
Aboriginal Health worker Occupational Therapist
Diabetes Educator Podiatrist
Exercise Physiologist Mental Health Worker
Other allied health programs under Medicare
There are a number of other funding programs available under Medicare. They include;
Helping Children with Autism package
- Follow up Allied Health Services for people of Aboriginal and Torres Strait Islander descent.
Phone: 132 011
Website: www. medicareaustralia.gov.au
Department of Health and Ageing
Phone: 1800 020 103
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