Medicare - Allied Health Services for Complex and Chronic Conditions
Chronic Disease Management (CDM) Items
- previously known as Enhanced Primary Care (EPC) Program
Information for Speech Pathologists
In summary:
- Speech pathologist must be registered with Medicare Australia
- GP assesses client’s eligibility for EPC plan, prepares a GP Management Plan and Team Care Arrangements and makes referral to speech pathologist
- Client cannot claim rebate until referral form received by speech pathologist
- Speech pathologist must provide client with a receipt with all required details (including item number 10970)
- Speech pathologist must report to referring GP at completion of first and last service
Registration with Medicare
For clients to be able to claim a Medicare rebate, the treating speech pathologist must be registered with Medicare Australia.
Speech pathologists who are working in private practice and who meet the specific eligibility criteria can register with Medicare. Upon registration Medicare will issue the speech pathologist with a provider number.
If a speech pathologist changes the location of their work or commences work in an additional location they must notify Medicare of these changes. A new or additional provider number will be issued.
Provider numbers may be closed if no longer required.
Eligibility criteria for allied health professionals providing new Medicare services
Application for an initial Medicare provider/registration for an Allied Health Professional
Application for an additional location - Medicare provider/registration number
Eligible Clients
The GP determines the client’s eligibility for the program.
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 (or is likely to be) 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.
Residents of aged care facilities may also be eligible for this program.
Hospital in-patients are not eligible for the EPC program.
If a client has chronic and complex care needs it is important for the speech pathologist to develop a close relationship with that client’s GP. By providing information of a client’s speech pathology difficulties and needs the speech pathologist may seek the GP’s consideration for that client to be included in the EPC program (see proforma following).
The speech pathologist may not provide part completed EPC referral forms for the GP to sign or pre-empt the GP’s decision about the service required by the client.
PROFORMA- Letter to GP providing information regarding client
Client Record - CDM Plan
Referral from GP
The GP will make the referral using an EPC referral form. The patient cannot claim the rebate from Medicare until the speech pathologist receives the referral form.
The GP nominates the number of services (sessions) up to a maximum of 5 per client per calendar year. The five sessions may be made up of one type of service (e.g., speech pathology) or a combination of different types of services (e.g., speech pathology and occupational therapy).
If all sessions are not used during the calendar year in which the patient was referred, the unused sessions can be used in the next calendar year. However, those sessions will be counted as part of the five rebates for allied health services available to the patient 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 in their plan.
The referral form must be retained for 24 months.
Session requirements
Each session must be of at least 20 minutes duration and be provided to an individual patient. The speech pathologist named on the referral form must be the person providing the service. If the client is to be seen by an alternative speech pathologist to the one named on the referral form a new referral form needs to be written by the GP.
Reporting to GP
Acknowledgement of the referral is recommended.
If the client is referred for a single service the treating speech pathologist is required to provide a written report to the referring GP at completion of the service.
Where a speech pathologist is providing multiple services to the same client under the one referral, they must provide a written report at completion of the first and last service, or more often if deemed clinically necessary.
The report should provide a summary of any assessment results, therapy outcomes and ongoing speech pathology needs of the patient.
PROFORMA- REPORT TO GP (Acceptance of referral OR Completion of first service/session)PROFORMA-REPORT TO GP (Completion of speech pathology service/s)
Rebate
A Medicare rebate of $50.05 per session is available (as at December 2010).
The rebate is indexed on 1st of November each year.
The speech pathologist may set their own fee.
Speech Pathologists can contact Medicare Australia on 132 150 to confirm how many allied health services have been claimed by a client within a calendar year.
Billing requirements
At completion of each service and upon payment of the invoice the speech pathologist provides the patient with a receipt.
The receipt must include:
- patient’s name
- date of service
- MBS item number (10970)
- speech pathologist’s name and provider number
- referring GP’s name and provider number
- date of referral
- amount charged, total amount paid, and any amount outstanding in relation to the service
- speech pathologist’s signature
Private Health Insurance
Patients with private health insurance cannot claim a rebate from their health fund in addition to the rebate from Medicare for a service.
Medicare Safety Net
Out of pocket expenses for these services count towards the extended Medicare safety net.
Information regarding Medicare safety net here
Other eligible allied health professionals
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
- Audiologist
- Chiropractor
- Diabetes Educator
- Dietician
- Exercise Physiologist
- Occupational Therapist
- Osteopath
- Physiotherapist
- Podiatrist
- Psychologist
- Mental Health Worker
Other Allied Health Initiative (Medicare) programs
There are a number of other funding programs available under Medicare. They include;Online Learning Tool - 'Medicare and You'
'Medicare and You’ is an eLearning program designed to help health care professionals better understand the Medicare program and their obligations when working with the Medicare Benefits Schedule.
'Medicare and You’ is free to access and easy to use. Each module is self-paced, interactive and case based. Topics covered include:
What is Medicare?
How to use the MBS
Patient consultations (attendances)
Enhanced primary care
Medicare billing and claiming
Additional Medicare billing information
Referrals and requests
For more information, or to access the ‘Medicare and You’ modules, please visit:
http://www.medicareaustralia.gov.au/provider/business/education/index.jsp
Quick reference guide for allied health professionals
Contact Details
Medicare
Phone: 132 011
Website: www. medicareaustralia.gov.au
Department of Health and Ageing
Phone: 1800 020 103
Website: http://www.health.gov.au/epc
