I remember before Autism, Medicare used to be really simple. You got a doctors bill and you took it to Medicare and then depending on what it was and how much you had already spent that year, you got back some money. Really simple. I remember when I was pregnant I used to go to Medicare regularly … but it was really simple. However, unfortunately, this is not the case when it comes to managing the paperwork for a child with Autism. I know when I was starting I found it a bit confusing .. but I hope that I can help someone out there with some of the things I have learnt.

• Enhanced Primary Care (EPC) (DOHA)
• Better Outcomes for Mental Health (DOHA)
• Helping Children with Autism – Treatment

Health Care Plans

Enhanced Primary Care

• Enhanced Primary Care Plan is for people with chronic or complex health conditions.
• Enhanced Primary Care Plan must be prepared by your GP (Item 721 or 725)
• Maximum of 5 sessions per calendar year
• Unused sessions can not be transferred to the next year
• Enhanced Primary Care Plan can be used by GPs to refer to Allied Professionals – Psychologists (Item 10968), Occupational Therapists(Item 10958), Speech Therapists(Item 10970), Physiotherapy (Item 10960) and Dietitians (Item 10954)
• Enhanced Primary Care Plan requires the GP to specify how many services to what professional. So you need to know how you want to allocate them before you get to the office.
• Medicare rebate of $47.85 per service, with out-of-pocket costs counting towards the extended Medicare Safety Net. You get more back if you have already reached your safety net

For more information visit the Department of Health and Ageing

Better Outcomes for Mental Health

• Better Outcomes for Mental Health Plan is for people with identified Mental Health needs that would be best serviced by Allied Health Professionals.
• Better Outcomes for Mental Health Plan can be prepared by your GP (Item 2710) or Pediatrician (Item 2702)
• Number of Visits – Unfortunately this was affected by cuts in the recent budget. Changes will be implemented from 1 November 2011. See Medicare for more details
  • On or Before October 31 2011 – up to 12 individual sessions (with the possibility of an additional 6 if deemed required by referring GP or Pediatrician) per calendar year and up to 12 group sessions per calendar year
  • After 1 November 2011 – Maximum of 10 visits per calendar year
• Unused sessions can not be transferred to the next year
• Better Outcomes for Mental Health Plan can be used by GPs and Pediatrician to refer to Allied Professionals – 1:1 Psychological Sessions (Item 80110),  Group Psychological Sessions (Item 80120) and OT
• Medicare rebate of $53-94 per service, with out-of-pocket costs counting towards the extended Medicare Safety Net. You get more back if you have already reached your safety net

For more information visit the Department of Health and Ageing Website

Helping Children with Autism (Treatment)

• Helping Children with Autism Package in addition to the $12,000 funding ($6000 a year for 2 years) has additional funding for Medicare treatment.
• Helping Children with Autism Treatment Plan can be prepared by Pediatrician (Item 135) or Psychiatrist (Item 135)
• Maximum of 20 sessions in total (not per year) to be used for the child from 0-15 years
• Helping Children with Autism Treatment Plan can be used by Pediatricians and Psychiatrists to refer to Allied Professionals – Psychological Sessions (Item 82015),  Speech Therapy (Item 82020) and OT (Item 82025)
• Medicare rebate of $69-75 per service, with out-of-pocket costs counting towards the extended Medicare Safety Net. You get more back if you have already reached your safety net

Medicare Safety Net

•  The Medicare Safety Net provides families and individuals with financial assistance for high out-of-pocket costs for out-of-hospital Medicare Benefits Schedule services. Once you meet a Medicare Safety Net threshold, you may be eligible for additional Medicare benefits for out-of-hospital MBS services for the rest of the calendar year.
• Medicare will pay 80% of out-of-pocket costs for out-of-hospital Medicare Benefits Schedule services once you have reached the safety net.
• You need to register to use the safety net … go now and do it now if you haven’t … here
• The Standard Threshold is $1157.50 however drops to $578.60 when your child has a Health Care Card (if you have a child with Autism, you should have a Health Care Card as it is provided with the Carer’s allowance).

For more details … see the Medicare website

Tips

If you want to get paid … Medicare Receipt requirements

For a Medicare payments to be made the account/receipt must include the following information:

• patient’s name;
• date of service;
• MBS item number;
• allied health professional’s name and provider number, or name and practice address;
• referring medical practitioner’s name and provider number, or name and practice address;
• date of referral; and
• amount charged, total amount paid, and any amount outstanding in relation to the service.

You may find that you need to get your account/receipts reissued with all the necessary information for Medicare (as your provider won’t know what you are claiming and when). If you turn up just with your account/receipts) without the Medicare Item numbers and the Care Plan Details they will reject them … trust me … it happened

Getting Set-Up

From my experience … the best way to get set-up is

1. Register for Medicare Safety Net 
2. Book 2 Long Appointments with GP. Most GP practices want you get book a long appointment for Health Care Plans. Check with their receptionist when you book appointment
3. Visit your GP and …
   1. Complete the Enhanced Primary Care Plan (Item 721 or 725)
   2. Get Referral to Pediatrician
   3. Get Referral for Treatment (for tax reasons)
4. Visit your GP and get the Better Outcomes for Mental Health Plan
5. Book appointment with Pediatrician
   1. Complete Helping Children with Autism Treatment Plan
   2. Get Referral for Treatment (for tax reasons)

Once you get each of your Treatment Plans and Referrals provide a copy (keep the original) to your provider. I prefer to scan them in and email them to my provider.

Summary

• Get all of your Health Care Plans as soon as possible. You can only claim from the date of your health care plan. Make sure that you keep them up-to-date.
• Get to know the Medicare Item Codes. This is the terminology that everyone talks in. If you don’t know it and use the name of the Health Care Plans most people (including Medicare employees) won’t be able to help you.
• All of your Medicare professional can only use 1 Medicare item code per visit. So if you need to get more than 1 health care plan from the same doctor you need to do 1 visit per health care plan
• Most doctors want you to book a long appointment for a Health Care Plan. Check when you book the appointment with the receptionist on the polciy used at that surgery.
• Make sure that you have all of your paperwork in order before you go to Medicare (especially the Receipt Requirements). If you don’t you will be sent away.

What have your experience been with Medicare? Do you have any lessons/scars? Please feel free to add links to more relevant information you have found useful in the comments below.