MEDICARE INFORMATION

Link to print this information is http://www.aass.org.au/medicare_schemes.pdf

There are a number of different plans or packages under Medicare which may enable families of children with a diagnosis of an Autistic Spectrum Disorder (ASD) to access services from a private provider and be rebated by Medicare.
Please note: the terms ASD and Pervasive Development Disorder (PDD) are interchangeable in this context.
The Helping Children with Autism Package New Medicare items that have been introduced as part of this Federal government package cover diagnosis and treatment.
Diagnosis
Medicare items have been introduced for:
Visits to consultant physicians (that is, paediatricians and psychiatrists) for them to diagnose and develop a treatment plan for children with a pervasive developmental disorder (PDD – that is, autistic disorder, Asperger syndrome/disorder, Rett’s syndrome, childhood disintegrative disorder or pervasive developmental disorder – not otherwise specified (PDD-NOS))
Child must be under the age of 13
Child must have been referred to the paediatrician / psychiatrist by a GP
Up to four visits to eligible allied health professionals (that is, psychologists, speech pathologists (SLP) and occupational therapists (OT)) to collaborate with the psychiatrist / paediatrician in assessing the child as part of the diagnostic process
Child must be under the age of 13
Child must have been referred to the allied health professional by the psychiatrist / paediatrician who is engaged in the process of diagnosing the child
Child must have been referred to the allied health professional for the purpose of assessment to assist in diagnosis of PDD & / or in the preparation of a treatment plan
Children who were already diagnosed before these new Medicare items were introduced can still use them to visit their paediatricians / psychiatrists specifically for the purpose of preparing a treatment plan and the paediatrician / psychiatrist can still refer the child for the 4 allied health professional visits for assessment to assist in the preparation of the treatment plan.
These Medicare items are only able to be claimed once in a child’s lifetime.
Treatment
Medicare items have been introduced for:
Up to 20 visits to eligible allied health professionals (psychologist, occupational therapist, speech pathologist) for treatment
Child must be under the age of 15
Child must be diagnosed with a PDD
Child must have a treatment plan which was prepared by a paediatrician / psychiatrist
Child must be referred to the allied health professional/s by the paediatrician / psychiatrist who prepared the treatment plan. This referral must consist of a letter from the paediatrician/psychiatrist
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addressed directly to each allied health professional (eg, one letter for the speech pathologist, one letter to the occupational therapist, etc) and must include:
The name and provider number of the referring the paediatrician / psychiatrist
A statement which outlines that the Helping Children with Autism package has been released for the child.
The item number, therapists name, clinic name and provider number. This information can be accessed from the therapist that you wish to be referred to.
After 10 sessions, the allied health professional/s must provide a report to the referring paediatrician / psychiatrist
These Medicare items are only able to be claimed once in a child’s lifetime.
The Better Access to Mental Health Professionals Plan
Under this Plan, Medicare items are available for:
Up to 12 visits per year to a psychologist or other eligible mental health professional (occupational therapist or social worker with recognised mental health experience and qualifications) for treatment
There are no age limits – available for children and adults
Patient must have a diagnosed mental disorder – a PDD is not considered a mental disorder, so an additional diagnosis is required; however, many of the associated symptoms of ASD are considered as mental disorders, so medical professionals are able to identify and diagnose an additional mental disorder alongside the ASD. Eligible mental disorders are: Anxiety disorder Adjustment disorder Depression Conduct disorders Sleep problems Attention deficit disorder Obsessive-compulsive disorder Eating disorders Psychotic disorders Schizophrenia Bipolar disorder Phobic disorder Sexual disorders Bereavement disorders Post-traumatic stress disorder Alcohol use disorder Co-occurring anxiety and depression Diagnosis and referral to the psychologist must be made by a General Practitioner (GP), psychiatrist or paediatrician
These visits are recurring – the person is entitled to 12 visits per year throughout life. However, unused visits from one year cannot be carried over into another year – 12 per year is the maximum.
Enhanced Primary Care
Under this initiative, Medicare items are available for:
Up to five allied health professional services per year
There are no age limits – available for children and adults
Patient must have a chronic condition and / or complex care needs. A chronic medical condition is one that has been (or is likely to be) present for six months or longer. Complex care needs are when a
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patient requires ongoing care from a multidisciplinary team consisting of their GP and at least two other health care providers. People with ASD therefore usually meet these criteria.
Patient must be referred directly to the allied health professional by a GP. That is, the plan must include the name and provider number of the allied health professional that you will be seeing.
Patient must have an Enhanced Primary Care (EPC) Plan prepared by their GP
Allied health professional/s must report back to the referring GP
Eligible allied health professionals for EPC are: Aboriginal health worker Audiologist Chiropractor Diabetes educator Dietician Exercise physiologist Mental health worker (includes Aboriginal health workers, mental health nurses, occupational therapists, psychologists and some social workers) Occupational therapist Osteopath Physiotherapist Podiatrist Psychologist Speech pathologist
Any combination of sessions is acceptable (eg., three with a dietician and two with a speech pathologist, or all with an occupational therapist)
These visits are recurring – the person is entitled to five visits per year throughout life. However, unused visits from one year cannot be carried over into another year – five per year is the maximum.
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It is worth reviewing all these options carefully to ensure that you get the best possible access to services.
Also, please note that under all these different initiatives, a treatment plan by the referring medical specialist is required – however, ideally, this treatment plan should be prepared by that medical specialist in consultation or discussion with the parent/s.
Finally, also please note that these items are only reclaimable from private providers. Of particular importance is the fact that you will have to see a private paediatrician or psychiatrist in order to gain referrals to any of the above allied health professionals – paediatricians / psychiatrists in the public health system are not able to refer, as they do not have a Medicare number.
For further information, see:
http://www.health.gov.au/autism
www.health.gov.au/epc
www.medicareaustralia.gov.au
or phone Medicare on 13 20 11
For information on Occupational Therapists with an interest in ASD: www.ausot.com.au/images/ASD%20Online%20Directory(1).pdf
For information on Speech Pathologists with an interest in ASD
email Speech Pathology Australia to access a list of speech pathologists with an interest in ASD:
office@speechpathologyaustralia.org.au
For information on Psychologists with an interest in ASD: www.psychology.org.au