Medicare Benefits Schedule - Item 10956

MENTAL HEALTH SERVICE

Mental health service provided to a person by an eligible mental health worker if:

(a)    the service is provided to a person who has:

1. a chronic condition; and
2. complex care needs being managed by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) under a shared care plan or under both a GP Management Plan and Team Care Arrangements or, if the person is a resident of an aged care facility, the person's medical practitioner has contributed to a multidisciplinary care plan; and

(b)    the service is recommended in the person's Team Care Arrangements, multidisciplinary care plan or shared care plan as part of the management of the person's chronic condition and complex care needs; and

(c)    the person is referred to the eligible mental health worker by the medical practitioner using a referral form that has been issued by the Department or a referral form that contains all the components of the form issued by the Department; and

(d)    the person is not an admitted patient of a hospital; and

(e)    the service is provided to the person individually and in person; and

(f)    the service is of at least 20 minutes duration; and

(g)    after the service, the eligible mental health worker gives a written report to the referring medical practitioner mentioned in paragraph (c):

    (i) if the service is the only service under the referral - in relation to that service; or

    (ii) if the service is the first or the last service under the referral - in relation to that service; or

    (iii) if neither subparagraph (i) nor (ii) applies but the service involves matters that the referring medical practitioner would reasonably expect to be informed of - in relation to those matters; and

(h)    for a service for which a private health insurance benefit is payable - the person who incurred the medical expenses for the service has elected to claim the Medicare benefit for the service, and not the private health insurance benefit;

- to a maximum of  five services (including any services to which items 10950 to 10970, 93000, 93013, 93501 to 93513 and 93524 to 93538 apply) in a calendar year

Fee: $65.85 Benefit: 85% = $56.00

(See para MN.3.1, MN.3.2, MN.3.3, MN.3.4, MN.3.5 of explanatory notes to this Category)

Extended Medicare Safety Net Cap: $197.55

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ELIGIBLE PATIENTS

Medicare benefits are available for certain services provided by eligible allied health professionals to people with chronic conditions and complex care needs who are being managed by a GP or medical practitioner using certain Chronic Disease Management (CDM) Medicare items or are enrolled in a Health Care Home.  The allied health services must be recommended in the patient's plan as part of the management of their chronic condition.

Chronic medical conditions and complex care needs

A chronic medical condition is one that has been or is likely to be present for at least six months, e.g. asthma, cancer, cardiovascular illness, diabetes mellitus, musculoskeletal conditions.and stroke.  A patient is considered to have complex care needs if they require ongoing care from a multidisciplinary team consisting of their GP or medical practitioner and at least two other health or care providers.

Prerequisite CDM services

Patients must have received the following MBS CDM services:

· GP Management Plan - MBS GP item 721 or medical practitioner item 229 (or GP review item 732 or medical practitioner review item 233 for a review of a GPMP); and

· Team Care Arrangements - MBS GP item 723 or medical practitioner item 230 (or GP review items 732 or medical practitioner review item 233 for a review of TCAs)

Alternatively, for patients who are permanent residents of an aged care facility, their GP or medical practitioner must have contributed to, or contributed to a review of, a multidisciplinary care plan prepared for them by the aged care facility (MBS GP item 731 or medical practitioner item 232).

Alternatively, for patients who are enrolled with a Health Care Home, a shared care plan must have been prepared by the medical practitioner who is leading the patient's care.

For more information on the CDM planning items, refer to the explanatory notes for these items.

Allied health membership of a TCAs team

The allied health professional providing the service may be a member of the TCAs team convened by the GP or medical practitioner to manage a patient's chronic condition and complex care needs.  However, the service may also be provided by an allied health professional who is not a member of the TCAs team, provided that the service has been identified as necessary by the patient's GP or medical practitioner and recommended in the patient's care plan/s.

Group services

In addition to individual services, patients who have type 2 diabetes may also access MBS items 81100 to 81125 which provide group allied health services.  Patients only need to have MBS GP items 721 or 723 or medical practitioner items 229 or 230 or a Health Care Home shared care plan in place to be eligible for the group services.

Related Items: 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970

Referral form

For Medicare benefits to be payable, the patient must be referred to an eligible allied health professional by their GP or medical practitioner using a referral form that has been issued by the Australian Government Department of Health or a form that contains all the components of this form.

The form issued by the department is available at www.health.gov.au/mbsprimarycareitems (click on the link for allied health individual services).

GPs and medical practitioners are encouraged to attach a copy of the relevant part of the patient's care plan to the referral form.

GPs and medical practitioners may use one referral form to refer patients for single or multiple services of the same service type (e.g. five chiropractic services).  If referring a patient for single or multiple services of different service types (e.g.  two dietetic services and three podiatry services), a separate referral form will be needed for each service type.

The patient will need to present the referral form to the allied health professional at the first consultation, unless the GP or medical practitioner has previously provided it directly to the allied health professional.

It is required that allied health professionals retain the referral form for 2 years from the date the service was rendered (for the Department of Human Services auditing purposes).

A copy of the referral form is not required to accompany Medicare claims, and allied health professionals do not need to attach a signed copy of the form to patients' itemised accounts/receipts or assignment of benefit forms.

Completed forms do not have to be sent to the Department of Health.

Health Care Home shared care plan

A Health Care Home shared care plan means a written plan that is prepared for a patient enrolled at a Health Care Home trial site; is prepared by a medical practitioner (including a general practitioner but not including a specialist or consultant physician) who is leading the patient's care at the Health Care Home trial site; and includes:  an outline of the patient's agreed current and long-term goals; the person or people responsible for each activity; arrangements to review the plan by a day mentioned in the plan; and if authorised by the patient, arrangements for the transfer of information between the medical practitioner and other health care providers supporting patient care about the patient's condition or conditions and treatment. A Health Care Home Shared care plan must be kept for 2 years after the date it was created.

Referral validity

Medicare benefits are available for up to five allied health services per patient per calendar year.  Where a patient receives more than the limit of five services in a calendar year, the additional service/s will not attract a Medicare benefit and the MBS Safety Net arrangements will not apply to costs incurred by the patient for the service/s.

If a patient has not used all of their allied health services under a referral in a calendar year, it is not necessary to obtain a new referral for the "unused" services.  However, any "unused" services received from 1 January in the following year under that referral will count as part of the total of five services for which the patient is eligible in that calendar year.

When patients have used all of their referred services, or require a referral for a different type of allied health service recommended in their CDM plan/s or Health Care Home shared care plan, they will need to obtain a new referral from their GP or medical practitioner.  GPs and medical practitioners may choose to use this visit to undertake a review of the patient's CDM plan/s or, where appropriate, to manage the process using a GP/medical practitioner consultation item.

It is not necessary to have a new CDM plan/s prepared each calendar year in order to access a new referral/s for eligible allied health services.  Patients continue to be eligible for rebates for allied health services while they are being managed under the prerequisite CDM items or Health Care Home shared care plan as long as the need for eligible services continues to be recommended in their plan.  However, regular reviews using MBS GP item 732 or medical practitioner item 233 are encouraged.

Related Items: 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970

Eligible allied health providers

The following allied health professionals are eligible to provide services under Medicare for patients with a chronic or terminal medical condition and complex care needs when they meet the provider eligibility requirements set out the next section and are registered with the Department of Human Services.

• Aboriginal and Torres Strait Islander health practitioners

• Aboriginal health workers

• Audiologists

• Chiropractors

• Diabetes educators

• Dietitians

• Exercise physiologists

• Mental health workers

• Occupational therapists

• Osteopaths

• Physiotherapists

• Podiatrists

• Psychologists

• Speech pathologists

Number of services per year

Medicare benefits are available for up to five allied health services per eligible patient, per calendar year.  The five allied health services can be made up of one type of service (e.g. five physiotherapy services) or a combination of different types of services (e.g. one dietetic and four podiatry services).  Five services per calendar year are the legal maximum per patient and exemptions to this are not possible.

Checking patient eligibility for allied health services

Patients seeking Medicare rebates for allied health services will need to have a valid referral form.  If there is any doubt about a patient's eligibility, the Department of Human Services will be able to confirm the number of allied health services already claimed by the patient during the calendar year.  The allied health professional or the patient can call the Department of Human Services to check this information (132 150 for provider enquiries; 132 011 for public enquiries).

Service length and type

Individual allied health services under Medicare for patients with a chronic medical condition and complex care needs (items 10950 to 10970) must be of at least 20 minutes duration and provided to an individual patient, not to a group.  The allied health professional must personally attend the patient.

Reporting back to the Practitioner

Where an allied health professional provides a single service to the patient under a referral, they must provide a written report back to the referring GP or medical practitioner after each service.

Where an allied health professional provides multiple services to the same patient under the one referral, they must provide a written report back to the referring GP or medical practitioner after the first and last service only, or more often if clinically necessary.  Written reports should include:

• any investigations, tests, and/or assessments carried out on the patient;

• any treatment provided; and

• future management of the patient's condition or problem.

The report to the Practitioner must be kept for 2 years from the date of service.

Out-of-pocket expenses and Medicare Safety Net

Allied health professionals can determine their own fees for the professional service.  Charges in excess of the Medicare benefit are the responsibility of the patient.  However, out-of-pocket costs will count toward the Medicare Safety Net for that patient.  Allied health services in excess of five in a calendar year will not attract a Medicare benefit and the Safety Net arrangements will not apply to costs incurred by the patient for such services.

Publicly funded services

Items 10950 to 10970 do not apply for services that are provided by any Commonwealth or state funded services or provided to an admitted patient of a hospital.  However, where an exemption under subsection 19(2) of the Health Insurance Act 1973 has been granted to an Aboriginal Community Controlled Health Service or state/territory government health clinic, items 10950 to 10970 can be claimed for services provided by eligible allied health professionals salaried by, or contracted to, the service or health clinic.  All requirements of the relevant item must be met, including registration of the allied health professional with the Department of Human Services.  Medicare services provided under a subsection 19(2) exemption must be bulk billed (i.e. the Medicare rebate is accepted as full payment for services).

Private health insurance

Patients need to decide if they will use Medicare or their private health insurance ancillary cover to pay for these services.  Patients cannot use their private health insurance ancillary cover to 'top up' the Medicare rebate paid for the services.

Related Items: 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970

The individual allied health items (10950 to 10970) can only be claimed for services provided by eligible allied health professionals who are registered with the Department of Human Services.  To be eligible to register with the Department of Human Services to provide these services, allied health professionals must meet the specific eligibility requirements detailed below. 

Aboriginal and Torres Strait Islander health practitioners must be registered with the Aboriginal and Torres Strait Islander Health Practice Board of Australia.  Aboriginal and Torres Strait Islander health practitioners may use any of the titles authorised by the Aboriginal and Torres Strait Islander Health Practice Board: Aboriginal health practitioners; Aboriginal and Torres Strait Islander health practitioners; or Torres Strait Islander health practitioners. 

Aboriginal health workers in a State or Territory other than the Northern Territory must have been awarded either:

a.   a Certificate III in Aboriginal and/or Torres Strait Islander Primary Health Care (or an equivalent or higher qualification) by a registered training organisation; or

b.   a Certificate III in Aboriginal and Torres Strait Islander Health (or an equivalent or higher qualification) by a registered training organisation before 1 July 2012. 

Note: Where individuals consider their qualification to be equivalent to or higher than the qualifications listed above, they will need to contact a registered training organisation in their State or Territory to have the qualification assessed as such before they can register with the Department of Human Services.  In the Northern Territory, a practitioner must be registered with the Aboriginal and Torres Strait Islander Health Practice Board of Australia. 

Audiologists must be either a 'Full Member' of the Audiological Society of Australia Inc (ASA), who holds a 'Certificate of Clinical Practice' issued by the ASA; or an 'Ordinary Member - Audiologist' or 'Fellow Audiologist' of the Australian College of Audiology (ACAud). 

Diabetes educators must be a Credentialled Diabetes Educator (CDE) as credentialled by the Australian Diabetes Educators Association (ADEA). 

Chiropractors must be registered with the Chiropractic Board of Australia. 

Dietitians must be an 'Accredited Practising Dietitian' as recognised by the Dietitians Association of Australia (DAA). 

Exercise physiologists must be an 'Accredited Exercise Physiologist' as accredited by Exercise and Sports Science Australia (ESSA). 

Mental health workers 

'Mental health' can include services provided by members of five different allied health professional groups.  'Mental health workers' are drawn from the following: 

-           psychologists;

-           mental health nurses;

-           occupational therapists;

-           social workers;

-           Aboriginal and Torres Strait Islander health practitioners; and

-           Aboriginal health workers. 

Psychologists, occupational therapists, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers are eligible in separate categories for these items. 

Mental health nurses must be a credentialled mental health nurse, as certified by the Australian College of Mental Health Nurses. 

Mental health nurses who were registered in the ACT or Tasmania prior to the introduction of the National Registration and Accreditation Scheme (NRAS) on 1 July 2010, will have until 31 December 2010 to be certified by the Australian College of Mental Health Nurses. 

Social workers must be a 'Member' of the Australian Association of Social Workers (AASW) and be certified by AASW as meeting the standards for mental health set out in the document published by AASW titled 'Practice Standards for Mental Health Social Workers' as in force on 8 November 2008. 

Occupational therapists must be registered with the Occupational Therapy Board of Australia. 

Osteopaths must be registered with the Osteopathy Board of Australia. 

Physiotherapists must be registered with the Physiotherapy Board of Australia. 

Podiatrists must be registered with the Podiatry Board of Australia. 

Psychologists must hold general registration in the health profession of psychology under the applicable law in force in the State or Territory in which the service is provided. 

Speech pathologists must be a 'Practising Member' of Speech Pathology Australia. 

Registering with the Department of Human Services

Provider registration forms may be obtained from the Department of Human Services on 132 150 or at the Department of Human Services website. 

Chiropractors, osteopaths, physiotherapists and podiatrists who were already registered with the Department of Human Services on 1 July 2004 to order diagnostic imaging under Medicare, do not need to re-register to provide services under this initiative.  Allied health professionals registering with the Department of Human Services for the first time only need to fill in one application form which will give them rights to provide services under this initiative and order diagnostic imaging tests etc., where appropriate, under Medicare. 

Changes to provider details

Allied health providers must notify the Department of Human Services in writing of all changes to mailing details to ensure that they continue to receive information about Medicare rebateable allied health services.

The individual allied health items (10950 to 10970) can only be claimed for services provided by eligible allied health professionals who are registered with the Department of Human Services.  To be eligible to register with the Department of Human Services to provide these services, allied health professionals must meet the specific eligibility requirements detailed below.

Related Items: 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970

Further information about Medicare Benefits Schedule items is available on the Department of Health's website at www.health.gov.au/mbsprimarycareitems 

Related Items: 10950 10951 10952 10953 10954 10956 10958 10960 10962 10964 10966 10968 10970