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Medicare

Funding For Diagnosis

In an ideal world, assessment and diagnosis would be rapid, professional and free.

There are many state-funded services which do provide diagnosis and some people are able access these without a long wait and without having to travel too far.

However, most state-funded assessment services have very long waiting lists and families can be left waiting for up to 12 months for an appointment. You may need or choose to use private professionals to do an assessment of your son or daughter. There are some funding options that can help.

Your GP can refer you to a paediatrician or psychiatrist for diagnosis, and there is a Medicare item number which can be claimed to pay for part of this cost.

The paediatrician or psychiatrist can then give you referrals to see up to another four professionals for diagnostic services such as audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists.

The Medicare item numbers cover part of the cost of their diagnostic assessments. These must be used by the child’s 13th birthday.

 

Information accurate as of September 2018.

Information accurate as of September 2018.

HCWA - Funding For Autism Treatment

There are Medicare rebates for up to 20 visits with health care professionals such as psychologists, speech pathologists, occupational therapists, audiologists, optometrists, orthoptists or physiotherapists.

These rebates cover a portion of the cost of the service. It’s important to note that 20 visits is the total number of Medicare claimable treatment sessions available to each child diagnosed with ASD up to the age of 15 years – not an annual entitlement.

A total of 20 treatment visits up to age 15 is not necessarily reflective of the number of visits a child with ASD might need to make measurable gains. We know they require intensive therapy if they are going to make any significant gains and learn the skills they need. This was however the number of visits the federal government chose to fund under the HCWA initiative.

The National Disability Insurance Scheme takes a very different approach to funding reasonable and necessary therapeutic supports for individuals with autism. See our NDIS page for more information

Better Access to Mental Health Care Scheme

The scheme is available to all Australians and we highly recommend you use it for anyone in your family or care where required. In particular if you are experiencing anxiety, depression or emotional strain it can be a huge help.

Many children, teenagers and adults on the autism spectrum take advantage of this program to help fund visits to a psychologist. Many parents and carers also access the scheme and find it very beneficial.

Under the scheme Medicare rebates are available to patients for selected mental health services provided by general practitioners (GPs), psychiatrists, psychologists (clinical and registered) and eligible social workers and occupational therapists.

Medicare rebates are available for up to ten individual and ten group allied mental health services per calendar year to patients with an assessed mental disorder who are referred by:

  • A GP managing the patient under a GP Mental Health Treatment Plan; or
  • Under a referred psychiatrist assessment and management plan; or
  • A psychiatrist or paediatrician

The first step to access the scheme is to see your GP who will assess whether you have a mental disorder and whether the preparation of a GP Mental Health Treatment Plan is appropriate for you.

Medicare recently added item codes for ‘telehealth’ 1:1 and group psychological services under the Better Access to Mental Health initiative. This could be particularly useful for those families in rural, remote and very remote areas of Australia where allied health services may be limited (refer to the Modified Monash Model of remoteness regions four to seven).   Item codes 80111, 80121, 80136 & 80146 allow for therapy delivered by videoconference to be claimed.

Information accurate as of September 2018.

Information accurate as of September 2018.

Chronic Disease Management Plan

Again this scheme is available to all Australians and is a means to access additional services for both people on the spectrum and their parents or carers.

A chronic medical condition is one that has been present for six months or longer. In the area of ASD the most common examples include: anxiety, depression or stress (PTSD). There is no list of eligible conditions. However, these items are designed for patients who require a structured approach to their care and to enable GPs to plan and coordinate the care of patients with complex conditions requiring ongoing care from a multidisciplinary team.

There are two types of plans that can be prepared by a GP for Chronic Disease Management (CDM): a GP Management Plans (GPMP) and a Team Care Arrangements (TCAs). If you have a chronic medical condition, your GP may suggest a GPMP. If you also have complex care needs and require treatment from two or more other health care providers, your GP may suggest TCAs as well. Upon assessment, your GP will advise the most suitable plan option for you or your child.

Under Chronic Disease Management Plan you can access rebates for five visits per calendar year to allied health professionals under the Medicare Benefits Schedule items 10950-10970. To the left, we’ve summarised the most common items codes for autism families.

Getting started

Access to all of these Medicare rebates starts with a visit to your GP. It is invaluable to find a GP who understands autism spectrum disorder and who is across all the different Medicare rebates that can be accessed.

Not all GP’s will be well versed in this area so it’s important to make sure you do your research and be well informed before you go see your GP.

Helpful resources

Autism HCWA – Department of Health

Search Current Rebates Available – Medicare Benefits Schedule

Better Access to Mental Health Care fact Sheet – Department of Health

Chronic Disease Management Plan fact sheet – Department of Health