Services for patients who have a chronic condition and complex care needs – individual allied health services (Items 10950 to 10970).

ELIGIBLE PATIENTS

Medicare benefits are available for certain services provided by eligible allied health professionals to people with chronic conditions and complex care needs who are being managed by a GP under an Chronic Disease Management (CDM) plan. The allied health services must be recommended in the patient’s CDM plan as part of the management of their chronic condition.

These items do not apply to services provided to an admitted patient of a hospital.

Chronic conditions and complex care needs

A chronic medical condition is one that has been or is likely to be present for at least six (6) months including, but not limited to, asthma, cancer, cardiovascular illness, diabetes mellitus, mental disorders, arthritis and musculoskeletal conditions. A patient is considered to have complex care needs if they require ongoing care from a multidisciplinary team consisting of their GP and at least two (2) other health care providers.

CDM plan
Patients are considered to be managed under an CDM plan if, during the last two years:

• their GP has put in place a GP Management Plan (MBS Chronic Disease Management
• (CDM) item 721) and Team Care Arrangements (MBS Chronic Disease Management
• (CDM) item 723); or
• their GP has reviewed their existing CDM plan MBS item 725 and 727; or
• their GP has contributed to or reviewed a multidisciplinary care plan prepared for them as
• a resident of an aged care facility and claimed item 731.

For more information on the CDM planning items, refer to the explanatory notes for these items in the general Medicare Benefits Schedule which can be found at www.health.gov.au/mbsonline.

CDM planning team

The allied health professional providing the service may be part of the CDM planning team convened by the GP to manage a patient’s chronic condition and complex care needs.  However, the service may also be provided by an allied health professional who is not part of the CDM planning team, provided that the service has been identified as necessary by the patient’s GP and recommended in their CDM plan.

Group services

In addition to individual services, patients who have type 2 diabetes may also access MBS items 81100 to 81125 which provide allied health group services – refer Part 3.

ELIGIBLE ALLIED HEALTH SERVICES

Eligible allied health professionals The following groups of allied health professionals are eligible to provide individual services under Medicare for patients with a chronic condition and complex care needs:

• Aboriginal health workers
• Audiologists
• Chiropractors
• Diabetes Educators
• Dietitians
• Exercise Physiologists
• Mental Health Workers
• Occupational Therapists
• Osteopaths
• Physiotherapists
• Podiatrists
• Psychologists
• Speech Pathologists

Number of services per year

Medicare benefits are available for up to five (5) allied health services per eligible patient, per calendar year. If more than five services are provided in a calendar year, the subsequent service/s will not attract a Medicare rebate and the MBS Safety Net arrangements will not apply to costs incurred by the patient for the service/s.

The five allied health services can be made up of one type of service (eg five physiotherapy services) or a combination of different types of services (eg one dietetic and four podiatry services).

If there is any doubt about a patient’s eligibility, Medicare Australia will be able to confirm the number of allied health services already claimed by the patient in the calendar year. The allied health professional or the patient can call Medicare Australia on 132 011 to check this information.

Service length and type

Services provided under these allied health items must be of at least 20 minutes duration and be provided to an individual patient, not to a group. The allied health professional must personally attend the patient.

Reporting requirements

The allied health professional must provide a written report back to the referring GP after the first and last service, or more often if clinically necessary. Written reports should include:

• any investigations, tests, and/or assessments carried out on the patient;
• any treatment provided; and
• future management of the patient’s condition or problem.

Out-of-pocket expenses and Medicare Safety Net

Allied health professionals are free to determine their own fees for the professional service.  Charges in excess of the Medicare benefit are the responsibility of the patient. However, out-of-pocket costs will count toward the Medicare Safety Net for that patient. Allied health services in excess of five (5) in a calendar year will not attract a Medicare benefit and the Safety Net arrangements will not apply to costs incurred by the patient for such services.

Publicly funded services

Items 10950 to 10970 do not apply for services that are provided by any Commonwealth or State or Territory funded services or provided to an admitted patient of a hospital.

However, where an exemption under subsection 19(2) of the Health Insurance Act 1973 has been granted to an Aboriginal Community Controlled Health Service or State/Territory Government health clinic, items 10950 to 10970 can be claimed for services provided by eligible allied health professionals salaried by, or contracted to, the Service or health clinic. All requirements of the relevant item must be met, including registration of the allied health professional with Medicare Australia.

Private health insurance

Patients need to decide if they will use Medicare or their private health insurance ancillary cover to pay for these services. Patients cannot use their private health insurance ancillary cover to ‘top up’ the Medicare rebate paid for the services.

ALLIED HEALTH SERVICES (CDM) REFERRAL REQUIREMENTS

Referral form

For Medicare benefits to be payable, the patient must be referred to an eligible allied health professional by their GP using an CDM program referral form for allied health services under Medicare – refer Appendix 1. GPs are encouraged to attach a copy of the relevant part of the patient’s care plan to the referral form.

GPs may use one referral form to refer patients for single or multiple services of the same service type (eg five chiropractic services). If referring a patient for single or multiple services of different service types (eg two dietetic services and three podiatry services), a separate referral form will be needed for each service type.

The patient will need to present the referral form to the allied health professional at the first consultation, unless the GP has previously provided it directly to the allied health professional.

Allied health professionals are required to retain the referral form for 24 months from the date the service was rendered (for Medicare Australia auditing purposes).

A copy of the referral form is not required to accompany Medicare claims, and allied health professionals do not need to attach a signed copy of the form to patients’ itemised accounts/receipts or assignment of benefit forms.

The referral form can be downloaded from the Department of Health and Ageing website at www.health.gov.au/epc or ordered by faxing (02) 6289 7120 or phoning (02) 6289 4297. GPs may modify the referral form to suit their practice needs (for example, relevant software packages) as long as the information is substantially retained.

Referral validity

A referral is valid for the stated number of services. If all services are not used during the calendar year in which the patient was referred, the unused services can be used in the next calendar year. However, those services will be counted as part of the five rebates for allied health services available to the patient during that calendar year.

When all referred services have been used, or a referral for a different type of allied health service is required, patients need to obtain a new referral from their GP. GPs may choose to use this visit to undertake a review of the patient’s CDM plan or, where appropriate, to manage the process using a GP consultation item.

It is not necessary to have a new CDM plan prepared each calendar year in order to access a new referral(s) for eligible allied health services. Patients continue to be eligible for rebates for allied health services while they are being managed under an CDM plan as long as the need for eligible services continues to be recommended in their plan.

ALLIED HEALTH PROFESSIONAL ELIGIBILITY

The allied health items (10950 to 10970) can only be claimed for services provided by eligible allied health professionals who are registered with Medicare Australia. To be eligible to register with Medicare Australia to provide these services, allied health professionals must meet the specific eligibility requirements detailed below:

Aboriginal Health Workers practising in the Northern Territory must be registered with the Aboriginal Health Workers Board of the NT; in other States and the Australian Capital Territory they must have been awarded a Certificate Level III in Aboriginal and Torres Strait Islander Health (or an equivalent or higher qualification) from a Registered Training Organisation that meets training standards of the Australian National Training Authority’s
Australian Quality Training Framework.  Note: Where individuals consider their qualification to be equivalent to or higher than a Certificate Level III in Aboriginal and Torres Strait Islander Health, they will need to contact a Registered Training Organisation in their State to have the qualification assessed as such before they can register with Medicare Australia.

Audiologists must be either a ‘Full Member’ of the Audiological Society of Australia Inc (ASA), who holds a ‘Certificate of Clinical Practice’ issued by the ASA; or an ‘Ordinary Member – Audiologist’ or ‘Fellow Audiologist’ of the Australian College of Audiology (ACAud).

Chiropractors must be registered with the Chiropractors (or Chiropractors and Osteopaths) Registration Board in the State or Territory in which they are practising.

Diabetes Educators must be a Credentialed Diabetes Educator (CDE) as credentialed by the Australian Diabetes Educators Association (ADEA).

Dietitians must be an ‘Accredited Practising Dietitian’ as recognised by the Dietitians Association of Australia (DAA).

Exercise Physiologists must be an ‘Accredited Exercise Physiologist’ as accredited by the Australian Association for Exercise and Sports Science (AAESS).

Mental Health Workers – ‘Mental health’ can include services provided by members of five different allied health professional groups. ‘Mental health workers’ are drawn from the following:

• psychologists;
• mental health nurses;
• occupational therapists;
• social workers; and
• Aboriginal health workers.

Psychologists, occupational therapists and Aboriginal health workers are eligible in separate categories for these items.

A mental health nurse may qualify if they are:

• a registered mental health nurse in Tasmania or the Australian Capital Territory (ACT), if providing mental health services in Tasmania or the ACT; or
• a ‘Credentialed Mental Health Nurse’ as certified by the Australian College of Mental Health Nurses, if providing mental health services in other States or the Northern Territory.

A social worker must be a ‘Member’ of the Australian Association of Social Workers (AASW) and be certified by AASW as meeting the standards for mental health set out in AASW’s ‘Standards for Mental Health Social Workers 1999’, as in force on 1 November 2006.

Occupational Therapists in Queensland, Western Australia, South Australia and the Northern Territory must be registered with the Occupational Therapists Board in the State or Territory in which they are practising. In other States and the Australian Capital Territory, they must be a ‘Full-time Member’ or ‘Part-time Member’ of OT AUSTRALIA, the national body of the Australian Association of Occupational Therapists. Please note: there are additional registration requirements to provide services under the Focussed Psychological Strategies Services.

Osteopaths must be registered with the Osteopaths (or Chiropractors and Osteopaths) Registration Board in the State or Territory in which they are practising.

Physiotherapists must be registered with the Physiotherapists Registration Board in the State or Territory in which they are practising.

Podiatrists in all States and the Australian Capital Territory must be registered with the Podiatrists Registration Board in the State or Territory in which they are practising. If practising in the Northern Territory, Podiatrists must be registered with the Podiatrists Registration Board in any other State or the Australian Capital Territory, or be a “Full Member” of the Australian Podiatry Association (ApodA) in any other State or the Australian Capital Territory.

Psychologists must be registered, without limitation, with the Psychologists Registration Board in the State or Territory in which they are practising. Psychologists whose State or Territory registration includes any limitation, for example, where marked ‘provisional registration’, are not eligible to register with Medicare Australia to use item 10968.

Speech Pathologists in Queensland must be registered with the Speech Pathologist Board of Queensland. In all other States, the Australian Capital Territory and the Northern Territory, they must be a ‘Practising Member’ of Speech Pathology Australia.  A copy of these eligibility requirements can be obtained from Medicare Australia by calling 132 150 or at www.medicareaustralia.gov.au or www.health.gov.au/epc.

REGISTERING WITH MEDICARE AUSTRALIA

Provider registration forms can be obtained from Medicare Australia on 132 150 or at www.medicareaustralia.gov.au (search for ‘allied health application’).

Chiropractors, osteopaths, physiotherapists and podiatrists who are already registered with Medicare Australia to order diagnostic imaging under Medicare, do not need to re-register to provide services under this initiative. Allied health professionals registering with Medicare Australia for the first time only need to fill in one application form which will give them rights to provide services under this initiative and order diagnostic imaging tests etc., where appropriate, under Medicare.

CHANGES TO PROVIDER DETAILS

Allied health providers must notify Medicare Australia in writing of all changes to mailing details to ensure that they continue to receive this publication and any updates about Medicare rebateable allied health services.