We help you understand your Medicare entitlements and/ or private healthcare coverage for your physiotherapy sessions.
Chronic pain is a complex and chronic condition that requires comprehensive assessment and management by a multidisciplinary team. After a comprehensive assessment by your pain specialist, physiotherapy will likely be recommended as part of the multidisciplinary treatment plan for you. Your general practitioner can recommend an allied health treatment plan as part of a Team Care Arrangement (TCA), which is the same as an Enhanced Primary Care Plan or Chronic Disease Management plan (CDM).
With your TCA in place, your specialist or general practitioner will send a new referral to your physiotherapist to enable you to attend an initial assessment. The physiotherapist will take a detailed history and conduct a physical examination and develop a treatment plan.
The treatment plan may include a combination of education, exercise, manual therapy, and other modalities. The physiotherapist will also work with you to set realistic goals and help you manage your pain so that you can resume normal activities.
Allied health providers included in the 5 sessions of the team care arrangement could be physiotherapists, exercise physiologists, dieticians, speech pathologists, etc.
Physiotherapy covered by Medicare
When is physiotherapy covered under Medicare?
Physiotherapy can be covered by Medicare if you are suffering from a chronic medical condition, such as chronic pain that needs specific treatment under an enhanced primary care plan or TCA.
What is considered a chronic and complex condition that would be covered under the enhanced primary care program?
An issue that has been present or is expected to be present for at least six months, is referred to as a chronic condition. These conditions can be treated under an enhanced primary care plan.
In addition to the condition being present for more than 6 months, for your condition to be considered complex, there must be 3 or more healthcare providers caring for you. If you are suffering from chronic pain, these healthcare providers often include your general practitioner, pain specialist, and physiotherapist but can include more practitioners, such as an occupational therapist, psychologist, psychiatrist, dietician, etc.
It is important to speak to your treating physiotherapist at your first consultation and inform them about your Team Care Arrangement so that they can advise you on how to access the Medicare rebates for your treatment sessions.
How many physiotherapy sessions are covered under the Medicare Rebate Cover?
Your Medicare entitlements under the team care arrangement cover up to five physiotherapy treatment sessions per calendar year – this is reset on the 1st of January of the next calendar year.
It is important to remember that the physiotherapy sessions covered by Medicare are part of the 5-maximum allowed allied health services per calendar year.
Am I covered by Medicare?
You must hold a valid Medicare card to access the Medicare benefits for allied health providers, including physiotherapy.
If you are visiting Australia from a country with a reciprocal healthcare agreement, you should be eligible to enrol in receive Medicare coverage.
What is the Medicare rebate per physiotherapy session as per the Medicare Benefits Schedule?
The current Medicare rebate is $56.00 per consult, independent of the allied health service that you are attending.
How do I claim the Medicare rebate?
Once the TCA has been approved by your general practitioner, the Medicare rebate can be claimed. Most physiotherapy clinics will expect you to pay the full amount for your session when attending your session, and they will process the Medicare rebate for you at the time of attendance.
If you have a valid Medicare card, your Medicare rebate will be paid directly into your account. The Medicare rebate can also be claimed online via the Medicare website.
Will the Medicare rebate cover my full physiotherapy consultation fee?
Private physiotherapy clinics will usually not bulk bill Medicare, so there will be a gap payment for the rest of the fee.
Some private physiotherapy services will not bulk bill Medicare, so there will be a gap payment for the rest of the fee. Ensure that you are aware of the full fee charged for your physiotherapy appointments and whether gap payments will be required or not.
Do I receive a rebate for subsequent review consults?
If you are still within your 5 maximum allied health care consults in the calendar year, your subsequent consults after your initial assessment will be covered by Medicare.
However, if you have exhausted your maximum of 5 allied health service sessions under your enhanced primary care program, you will have to pay out of pocket for subsequent consultations.
How long does my chronic disease management plan cover my care?
Chronic disease management plan referrals will renew each calendar year. This means that you will be able to book five allied health sessions each year to help you manage your chronic health condition.
Private health insurance and physiotherapy
Does private health insurance cover physiotherapy?
Yes, most private health funds have an extras policy that covers out-of-hospital services such as physiotherapy, but it is important to note that most basic health insurance won’t include physiotherapy as standard.
Private health rebates for physiotherapy sessions will depend on your specific health fund and your level of coverage up to a determined limit as outlined by your insurer.
There might still be a gap payment payable if the private health rebate does not fully cover the physiotherapy session fee.
What are the benefits of private health insurance that includes extras coverage for physiotherapy sessions?
The five Medicare-funded physiotherapy sessions are often not sufficient to complete a treatment plan for chronic conditions such as chronic pain. patients often need support from multiple services, which means that the 5 allied health sessions covered by the Medicare rebates are exhausted early in the year, leading to significant out-of-pocket costs for the patient.
When a patient with a complex chronic disease has health insurance, which include has extras coverage, it can substantially reduce the out-of-pocket expenses over time.
Is there a waiting period for physiotherapy when I join a private health fund?
Yes, most private health funds have required waiting periods after joining the fund. It is important to read your individual policy clearly to understand when you can claim physiotherapy sessions under your new policy.
What does it mean if a practice is a Preferred Provider?
As a patient it is important to understand, that “Preferred Provider” or “Members First/ Choice” programs simply refer to the financial agreement between the practice/ provider and the health fund.
These terms can be misleading and are occasionally misinterpreted by patients as meaning that specific clinics/ services are “preferred” by GPs or specialists and offer a superior service compared to other clinics.
What are the financial benefits if the physiotherapy practice, I am attending is a preferred provider of my health fund?
If your physiotherapy practice is a preferred provider of your health fund, this will usually result in a lower gap payment for your treatment sessions if you are within the limit of your extras benefit as determined by your health fund.
Disclosure: The information in this article is not intended to replace information from Medicare or your private health care fund. Please consult with Medicare/ your private health fund or discuss your benefits further with your health care providers. Please note – we update our patient articles as regularly as possible, but there might be changes to Medicare benefits or health fund benefits prior to us being able to update our article.
References:
- Chronic disease individual allied health services Medicare items. https://www.servicesaustralia.gov.au/chronic-disease-individual-allied-health-services-medicare-items?context=20
- Chronic disease GP Management Plans and Team Care Arrangements. https://www.servicesaustralia.gov.au/chronic-disease-gp-management-plans-and-team-care-arrangements?context=20
Dr. Ilonka Meyer is the Clinical Director and Founder of MindBodyPainSpecialists. She also holds an appointment as Acting Director of the Pain Service and Pain Specialist at the Austin Hospital in Heidelberg, Melbourne. Ilonka has a strong interest in interventional pain treatments, peri-operative pain and medication optimisation and cancer pain.
Ilonka is skilled in Clinical Research, Medical Education, Coaching, and Healthcare Management. Her main research focus lies in interventional pain medicine in the peri-operative population, cancer pain and the health economic benefits of pain and medication optimisation in patients both pre-and postoperatively.