Medicare Benefits Schedule - Note MN.6.2

Eligible psychological therapy services

There are eight MBS items for the provision of individual psychological therapy services to eligible patients by a clinical psychologist (80000, 80005, 80010, 80015, 91166, 91167, 91181 and 91182). 

Clinical psychologists must meet the provider eligibility requirements set out below and be registered with Services Australia.

In these notes, 'GP' means a medical practitioner, including a general practitioner, but not including a specialist or consultant physician.

Referrals and Referral Validity

Services provided under the Psychological Therapy items will not attract a Medicare rebate unless:

• a referral has been made by a GP or medical practitioner who is managing the patient under a GP Mental Health Treatment Plan;
• a referral has been made by a medical practitioner (including a general practitioner, but not a specialist or consultant physician) who is managing the patient under a referred psychiatrist assessment and management plan; or
• a referral has been made by a psychiatrist or paediatrician from an eligible psychiatric or paediatric service (see Referral Requirements for further details regarding psychiatrist and paediatrician referrals).

Number of services per year

Medicare rebates are available for up to 10 individual mental health services in a calendar year. The services may consist of: GP/medical practitioner focussed psychological strategies services; and/or psychological therapy services delivered by clinical psychologists; and/or focussed psychological strategies - allied mental health services.

The referring practitioner can decide how many sessions the patient will receive in a course of treatment, within the maximum session limit for the course of treatment. The maximum session limit for each course of treatment is set out below:

• Initial course of treatment – a maximum of six sessions.
• Subsequent course of treatment – a maximum of six sessions up to the patient’s cap of ten sessions (for example, if the patient received six sessions in their initial course of treatment, they can only receive four sessions in a subsequent course of treatment).

The written report provided by the clinical psychologist following a course of treatment will be considered by the referring practitioner in assessing the patient's clinical need for further sessions after each course of treatment.

Patients will also be eligible to claim up to 10 separate services within a calendar year for group therapy services, see MN.6.7.  These group services are separate from the individual services and do not count towards the individual services per calendar year maximum associated with those items.

Please note if a referral does not specify whether the referral is for individual or group therapy, the patient can use a referral to access either individual or group therapy treatment options. The patient should speak to their GP about their treatment needs and the type of treatment that might be suitable in their particular circumstances.

In the instance where a patient has received the maximum services available under the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule initiative per calendar year and is considered to clinically benefit from some additional services, the patient may be eligible for Primary Health Networks (PHNs) funded psychological therapies if they meet relevant eligibility criteria for the PHN commissioned services. It is recommended that providers refer to their PHN for further guidance.

Referrals for the Additional 10 Sessions (available until 31 December 2022)

In response to the COVID-19 pandemic, the number of Medicare rebateable individual mental health services was temporarily increased from 10 to 20 per calendar year until 31 December 2022.

A patient does not need a new referral to access Better Access sessions from 1 January 2023. If the patient has a current referral (either for the initial 10 sessions or the additional 10 sessions) and has not used all of the sessions, they can use that referral to access sessions in 2023. However, they cannot receive more than 10 individual sessions in 2023.

Service length and type

Services provided by eligible clinical psychologists under these items must be within the specified time period within the item descriptor. 

It is expected that professional attendances at places other than consulting rooms would be provided where treatment in other environments is necessary to achieve therapeutic outcomes. 

In addition to psycho-education, it is recommended that cognitive-behaviour therapy be provided.  However, other evidence-based therapies ─ such as interpersonal therapy ─ may be used if considered clinically relevant.

Course of treatment and reporting back to the referring medical practitioner

Eligible patients can claim Medicare subsidies for up to 10 individual mental health services per calendar year.

Within this maximum service allocation, the clinical psychologist can provide one or more courses of treatment (additional information on course of treatment session limits is above). This enables the referring medical practitioner to consider a report from the clinical psychologist on the services provided to the patient, and the need for further treatment.

On completion of the initial course of treatment, the clinical psychologist must provide a written report to the referring GP or medical practitioner, which includes information on:

• assessments carried out on the patient;
• treatment provided; and
• recommendations on future management of the patient's disorder.

A written report must also be provided to the referring GP or medical practitioner at the completion of any subsequent course(s) of treatment provided to the patient.

Out of pocket expenses and Medicare safety net

Charges in excess of the Medicare benefit for these items are the responsibility of the patient. However, if a service was provided out-of-hospital, any out-of-pocket costs will count towards the Medicare safety net for that patient. The out-of-pocket costs for mental health services which are not Medicare eligible do not count towards the Medicare safety net.

Eligible patients

Individual psychological therapy service items apply to people with an assessed mental disorder and where the patient is referred by a GP or medical practitioner who is managing the patient under a GP Mental Health Treatment Plan, under a referred psychiatrist assessment and management plan, or on referral from an eligible psychiatrist or paediatrician.

The conditions classified as mental disorders for the purposes of these services are informed by the World Health Organisation, 1996, Diagnostic and Management Guidelines for Mental Disorders in Primary Care: ICD-10 Chapter V Primary Care Version.  For the purposes of these items, dementia, delirium, tobacco use disorder and mental retardation are not regarded as a mental disorder.

Checking patient eligibility for psychological therapy services

If there is any doubt about a patient's eligibility, Services Australia will be able to confirm whether a GP Mental Health Treatment Plan and/or a psychiatrist assessment and management plan is in place and claimed; or an eligible psychiatric or paediatric service has been claimed, as well as the number of allied mental health services already claimed by the patient during the calendar year.

Clinical psychologists can call Services Australia on 132 150 to check this information, while unsure patients can seek clarification by calling 132 011.

The patient will not be eligible if they have not been appropriately referred and a relevant Medicare service provided to them. If the referring service has not yet been claimed, Services Australia will not be aware of the patient's eligibility.  In this case the clinical psychologist should, with the patient's permission, contact the referring practitioner to ensure the relevant service has been provided to the patient.

Publicly funded services

Psychological therapy items do not apply for services that are provided by any other 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 clinic, the items apply for services that are provided by eligible clinical psychologists salaried by, or contracted to, the service as long as all requirements of the items are met, including registration with Services Australia.  These services must be direct billed (that is, 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: 80010

• Previous - Note MN.6.1
• Next - Note MN.6.3

Psychological therapy health service provided to a patient in consulting rooms by an eligible clinical psychologist if:

(a)  the patient is referred by a referring practitioner; and

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

(c)  at the completion of a course of treatment, the referring practitioner reviews the need for a further course of treatment; and

(d)  on the completion of the course of treatment, the eligible clinical psychologist gives a written report to the referring practitioner on assessments carried out, treatment provided and recommendations on future management of the patient’s condition; and

(e)  the service is at least 50 minutes duration

Fee: $161.20 Benefit: 85% = $137.05

(See para MN.6.2, MN.6.3, MN.6.4 of explanatory notes to this Category)