Getting the most out of Medicare

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Key facts

Medicare has been extended a lot in recent years.  For many people, it now covers much more than just going to the doctor when you are sick.  Read the Annual health assessments fact sheet to find out about Medicare health checks by GPs.  Other new parts of Medicare will also be useful to many people with intellectual disabilities. 

If you think that items in this fact sheet might be useful for a person with intellectual disability, take the fact sheet with you and ask the doctor. 

The Healthy Kids Check

Every four year old can have a health check by a GP.  The doctor can identify signs of a disability and provide advice on healthy lifestyles.

GP Management Plans and Team Care Arrangements

A GP can write a Management Plan for treatment of a chronic medical condition, eg diabetes, asthma, and heart disease.  If the person also has complex needs, the GP can coordinate a Team Care Arrangement with other health and care providers.

Allied health services

Allied health services include people like dietitians, physiotherapists, speech pathologists, audiologists, psychologists, occupational therapists and Aboriginal health workers.

Medicare covers allied health services for a person who has both a GP Management Plan and a Team Care Arrangement - up to 5 visits each year.  You need a GP’s referral.

Group services for people with type 2 diabetes

If a person has a GP Management Plan, the GP can refer the person for group sessions to help manage their diabetes.

Mental health care

GP Mental Health Care items apply to people with a “mental disorder”, eg anxiety or depression.  The GP can prepare a care plan and spend extra time with the person.  The GP can also refer the person to a psychologist who can be paid by Medicare.

Psychiatrists also have special Medicare items for people with disabilities.

Dental services

A person is eligible for Medicare coverage of dental services if their oral health is likely to affect their general health, and they have a GP Management Plan and Team Care Arrangements. See above.  Medicare will then pay for most dental services - up to $4,250 over two calendar years.  You need a GP’s referral.

Autism and similar conditions

For children under 13, Medicare covers diagnosis and treatment plans for autism and some similar conditions (called “pervasive developmental disorders”).  This work is done by a specialist paediatrician or child psychiatrist.  The specialist can also refer the child to a psychologist, speech pathologist or occupational therapist for help with the assessment and up to 20 sessions of early intervention.

Medicare also pays for ongoing care by a psychiatrist for children and adults who are seriously affected by autism or a similar condition.

Specialist physicians

These include paediatricians, adult physicians, neurologists etc.  A GP refers patients to them.  As well as standard consultations, Medicare has special items for a physician:

• Assessing and preparing a treatment plan for a person with intellectual disability and a complex health problem. 
  
• Organising or attending a case conference with a team of health and care workers.

Will Medicare cover the whole bill?

Medicare only covers the full fee if the heath professional bulk bills.  (If the person has a lot of medical expenses, the Extended Medicare Safety Net may cover some of the cost.)

If the person has private health insurance, that may cover some of the services in this fact sheet.  You cannot claim on both Medicare and private health insurance.

Remember that Medicare is for payment of private health professionals.  There are also some free health services provided by government. 

For more information

Enhanced Primary Care section of the Department of Health and Ageing website.   www.health.gov.au/internet/main/publishing.nsf/Content/Enhanced+Primary+Care+Program-1

Extended Medicare Safety Net
www.medicareaustralia.gov.au/public/services/msn/index.jsp

You might be interested in these fact sheets

Annual health assessments
Children – what kinds of health services are there?
Adults – what kinds of health services are there?
Going to the dentist
Mental Health

This fact sheet was written in July 2009.

The fact sheet contains general information only and does not take into account individual circumstances.  It should not be relied on for medical advice.  We encourage you to look at the information in this fact sheet carefully with your health professional to decide whether the information is right for you.