Is Physiotherapy covered by Medicare? Your complete guide

Wednesday, November 11, 2020

Understanding what’s covered by Medicare and what’s not can be complicated. Not to mention, figuring out which allied health services like physiotherapy are covered by Medicare can become even more of a headache.

In short, yes - physiotherapy is covered by Medicare. However, there are certain criteria you’ll have to meet in order to be eligible.

Here, we’ve got your ultimate guide to Medicare for physiotherapy.

  • What is Medicare?
  • What’s covered by Medicare?
  • Who’s covered by Medicare?
  • How to Claim a Medicare Benefit for Physiotherapy

Is Physiotherapy covered by Medicare?

What is Medicare?

Medicare is the universal healthcare system in Australia. It helps cover the costs of doctor’s appointments, medication, and other allied healthcare services like physical therapy or mental health treatment.

Once you enroll in Medicare, the system covers most or all of your healthcare costs. However, there are certain criteria one has to meet in order to receive these benefits.

Medicare physiotherapy sessions fall under what’s known as the Medicare Chronic Disease Management (CDM) scheme. The idea behind it is that those who suffer from chronic conditions can take a multidisciplinary approach to their treatment.

In other words, you might be sent to a physiotherapist by your GP for chronic musculoskeletal issues such as arthritis or a recurring knee injury versus only being treated by one type of healthcare provider.

So, in order to claim Medicare benefits for physiotherapy, you’ll need to follow the CDM guidelines. We’ll cover more on that down below.

What’s covered by Medicare?

Most healthcare services are covered, at least in part, by Medicare. These include:

  • GP or specialist visits
  • Tests and scans such as MRIs and x-rays
  • Most surgeries and procedures
  • Eye tests and optometry
  • Pregnancy, fertility treatments, and birth
  • Chronic conditions

As you can see, this doesn’t include some other healthcare services such as:

  • Ambulances
  • Most dental services
  • Glasses, contact lens, and hearing aids
  • Cosmetic surgery

This is why many Australians opt for private health insurance to cover everything else that Medicare doesn’t take care of.

So, what’s the short answer to the question, “Is physiotherapy covered by Medicare?”

Yes. Physiotherapy can be covered by Medicare so long as it’s a chronic and complex musculoskeletal condition requiring specific treatment under the CDM.

Medicare coverage for physiotherapy for chronic and complex conditions covers 85% of a $62.50 service for a rebate of $54.60, as of November 2020.

For a better understanding of what the Medicare Benefits Schedule defines as physiotherapy, you’ll want to refer to Item 10960. In summary, physiotherapy that can be covered by Medicare if the service is provided to a patient with a chronic condition requiring complex care.

Let’s explore what it means to have a chronic and complex condition.

Under the CDM plan, a chronic condition refers to an issue that has been or is expected to be present for at least six months. The tricky part is that there is no list of eligible chronic conditions to refer to. It’s sort of decided on a case by case basis.

However, many conditions that can be treated by physiotherapy fall under a CDM plan including arthritis and diabetes.

Additionally, physiotherapy benefits also need to be considered complex. A complex condition means that there must be three or more healthcare practitioners caring for you. This might include your GP, a podiatrist, a physio, and a dietician, for example.

There are other stipulations as well. You’ll need to be referred to a physio by your GP, the service being completed outside of hospital, the service should last at least 20 minutes, and there is a maximum of five (5) of allied health services available.

Again, refer to Item 10960 of the Medicare Benefits Schedule for a detailed breakdown.

Who’s covered by Medicare?

You must enrol in Medicare to be able to claim Medicare benefits for most healthcare services. You are eligible to enrol in Medicare Australia if you’re:

  • An Australian citizen
  • A New Zealand citizen
  • An Australian permanent resident
  • Applying for permanent residency in Australia
  • A temporary resident covered by a ministerial order

You are also eligible to enrol in Medicare Australia if you are a citizen or resident of:

  • Norfolk Island
  • Christmas Island
  • Cocos (Keeling) Island
  • Lord Howe Island

Additionally, if you are visiting Australia from a Reciprocal Healthcare Agreement country, you may also enrol and receive coverage from Medicare.

How to Claim a Medicare Benefit for Physiotherapy

Claiming a Medicare benefit for your physiotherapy appointment will vary from clinic to clinic in terms of protocol.

In most cases, when you claim a benefit from Medicare for physiotherapy, there are a few things to be sure of before you head to your appointment.

Chronic

Firstly, to receive Medicare physiotherapy benefits, you must have a chronic issue meaning it must have been or is expected to continue going on for at least six months. So, step one is to verify that you indeed have a chronic condition.

Complex

Next, you’ll need to confirm that your condition is complex. In order to qualify for Medicare benefits to cover your physiotherapy, you’ll also need to be under the care of at least two other healthcare practitioners.

For both of these stipulations, your GP will need to approve your eligibility with the necessary paperwork under the CDM.

Appointment Limits

Medicare also limits the number of Allied Health appointments you’re allowed during a 12-month period. You’re allotted five consultations per calendar year which can be divvied up between providers.

You might use all five of your consultations on physiotherapist appointments or you could make three physiotherapist consultations, one dietician consultation, and one podiatrist consultation to split things up.

This is another consideration to keep in mind before you see your physiotherapist if you’re hoping to have the appointment covered by Medicare.

Step-by-Step: How to Do a Medicare Claim for Physiotherapy

Claiming Medicare benefits for your physio is usually a smooth process if you meet the aforementioned criteria. Here’s what to do after confirming that you have a chronic and complex condition requiring physiotherapy.

Step 1: Book an appointment with your GP and ask them to fill out the CDM paperwork.

Step 2: Contact Physio Inq to make an appointment and bring your referral paperwork with you. Even better, we have our mobile physio services can come to you!
           
Step 3: Work with your expert physiotherapist on your chronic and complex musculoskeletal condition.

Step 4: Pay for the appointment. Then, you can either claim your Medicare rebate on your own or we can submit a claim for you. You’ll receive a rebate of $54.60, as of November 2020.

From there, if you have private health insurance, you’ll want to claim your Medicare benefits first. Then, you can use your private health to cover the rest.

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So yes, Medicare will cover your physiotherapy session but there are certain criteria you’ll have to meet. You’ll receive a $54.60 rebate for up to five physiotherapy appointments to treat chronic and complex conditions.

If you have a chronic and complex musculoskeletal condition, head to you GP for a referral and then contact your local Physio Inq clinic or book in with one of our Mobile & Home Physiotherapists We’ll help you make a Medicare claim for your physio appointment with us if you qualify.

This article was originally written by Jonathan Moody from Physio Inq

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