Frequently Asked Questions - Helping Children with Autism (HCWA) program

Frequently Asked Questions

Page last updated: 15 September 2016

Printable version of Frequently asked Questions (PDF 453 KB)
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Part 1 – General Information

Part 2 – Patient Eligibility for Medicare Items Under HCWA

Part 3 – Provider Information

Part 4 – Referral Pathways

Part 5 – Medicare Services

Part 6 – Other Initiatives and Further Information

Part 1 – General Information

In 2008, the Helping Children with Autism (HCWA) program created new items in the MBS to provide early intervention services from eligible allied health professionals (occupational therapists, psychologists, and speech pathologists) for children diagnosed with autism/pervasive development disorder (PDD).

Children eligible for the HCWA program have access to a broader range of allied health professionals. Medicare items are available for eligible children to access services from eligible audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists.

Medicare Benefits Schedule (MBS) rebates are available for
  • paediatricians and psychiatrists to diagnose and develop a treatment and management plan for a child with autism/PDD aged under 13 years after referral from a general practitioner (GP);
  • audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists to provide up to a total of four (4) services per child to collaborate with the paediatrician or psychiatrist on the assessment and development of the treatment and management plan; and
  • audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists to provide early intervention treatment services following diagnosis (up to a total of 20 services per child).

Part 2 – Patient Eligibility for Medicare Items Under HCWA

2.1 What conditions are eligible for the Medicare items under HCWA?
For the purposes of these services, the conditions classified as autism and any other PDDare informed by the “American Psychiatric Association: “Diagnostic and Statistical Manual of Mental Disorder”, Fifth Edition (DSM-5). It is the responsibility of the paediatrician or psychiatrist coordinating the child’s care to ensure the child meets the specified eligibility requirements.

2.2 What are the age limitations for the Medicare items under HCWA?
A child is eligible to access the autism program if he/she has a treatment and management plan provided by a paediatrician or psychiatrist (after referral from a general practitioner) before the child’s 13th birthday.

Treatment services must be completed before the child’s 15th birthday provided the treatment and management plan was in place before the child’s 13th birthday.

2.3 What should the paediatrician or psychiatrist do if there is a concern that the child may have autism/PDD, but the diagnosis is not clear at the initial consultation?
In the case of a child who has not been previously diagnosed with autism/PDD, an appropriate MBS item 110 to 131 for a paediatrician or 296 to 370 (excluding 359) for a psychiatrist can be billed for the initial attendance or assessment. If the treating paediatrician or psychiatrist forms a view that a more comprehensive assessment is warranted and needs to refer the child to allied health professionals for this purpose, subsequent attendances would be billed using one of MBS items
116 to 131 for a paediatrician and MBS items 296 to 370, excluding 359, for a psychiatrist, as appropriate.

Allied health professionals are expected to assess the child and report their assessment back to the referring practitioner as to whether or not the child has autism/PDD and advise the paediatrician or psychiatrist on the development of a treatment and management plan (if required).Top of page

2.4 How will children with an existing diagnosis benefit from this initiative?
MBS items (135 or 289) may be used to prepare a treatment and management plan for a child. It is expected that any existing diagnosis would feed into the treatment and management plan prepared through these items, if a further diagnosis is not needed. Once a treatment and management plan has been prepared, the relevant paediatrician or psychiatrist can then refer the child to allied health professionals for treatment services.

In the event that the existing diagnosis was undertaken by a different practitioner, it is a matter of clinical judgement by the treating paediatrician or psychiatrist whether to accept or review the existing diagnosis. If a further assessment is required, the treating paediatrician or psychiatrist may refer the child to allied health professionals for diagnostic assessment services, under one of the MBS items 110 to 131 or 296 to 370 excluding 359, as appropriate.

MBS item 135 or item 289 is billed once the paediatrician or psychiatrist is in a position to determine a diagnosis and develop a treatment and management plan. Subsequent attendances to review the child’s condition and the outcomes of the treatment and management plan would be billed under one of the MBS items 116 to 131 or 296 to 370 excluding 359, as appropriate. Where a review of a treatment plan is required, the consultant physician may refer the child to allied health professionals under one of the MBS items 116 to 131 or 296 to 370 excluding 359, as appropriate, for diagnostic assessment services (where maximum of 4 has not been achieved for that child) even after claiming MBS item 135 or 289.

2.5 My child has accessed Medicare services under the Better Start for Children with Disability (Better Start) initiative. Can he/she access services under the HCWA program?
No. Children can only access one of the HCWA or Better Start programs but not both. Allied health providers (audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists) and number of services are the same for both programs.

2.6 How can a child’s eligibility for allied health services be checked?
Children seeking Medicare rebates for autism/PDD allied health services will need to have a referral from a paediatrician or psychiatrist. If there is any doubt about a child’s eligibility, Medicare Australia will be able to confirm whether a relevant MBS service has been claimed from a paediatrician or psychiatrist (to facilitate access to the assessment items); or that an autism/PDD treatment and management plan has been claimed (to facilitate access to the treatment items), as well as the number of allied health autism/PDD services already claimed by the child.

Allied health professionals can call the Department of Human Services (Medicare) on 132 150, and parents and carers can call the Medicare on 132 011.

2.7 My child was registered under the HCWA program before 1 July 2011. Can he/she now access the additional allied health providers?
Yes. From 1 July 2011, all children accessing allied health providers under the HCWA program will have access to audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists, regardless of their date of commencement on the program, for the remainder of the services they are eligible for.

For example, if your child has had all four assessment services and ten (10) treatment services prior to 1 July 2011, he/she is still entitled to the remaining ten (10) treatment services, and may utilise the additional allied health providers for these services if clinically appropriate. The total number of services available for eligible children remains the same regardless of when your child first accessed the program, that is, four (4) assessment services and twenty (20) treatment services in their lifetime.

Part 3 – Provider Information

3.1 Which allied health professionals can provide services for children with autism/PDD?
Allied health services can be provided by eligible audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists.
Allied health professionals must be registered with Medicare Australia and be working in private practice.

3.2 What is the eligibility criteria for each allied health provider?
Allied health professionals providing services using the MBS items must be registered with Medicare. To be eligible to register with Medicare to provide these services, an allied health professional must meet the specific eligibility requirements detailed below:
  • Audiologist 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);
  • Occupational Therapist in Queensland, Western Australia, South Australia and the Northern Territory must be registered with the Occupational Therapists Board in the State or Territory in which they are practising; in other States and the Australian Capital Territory, they must be a ‘Full-time Member’ or ‘Part-time Member’ of Occupational Therapy Australia, the national body of the Australian Association of Occupational Therapists;
  • Optometrist must be registered as an optometrist or optician under a law of a State or an internal Territory that provides for the registration of optometrists or opticians, and be a participating optometrist;
  • Orthoptist must be registered with the Australian Orthoptic Board and have a Certificate of Currency; and be a member of Orthoptics Australia;
  • Physiotherapist must be registered with the Physiotherapy Board of Australia;
  • Psychologist must hold General Registration with the Psychology Board of Australia; or
  • Speech Pathologist in Queensland must be registered with the Speech Pathologist Board of Queensland. In all other States, the Australian Capital Territory and the Northern Territory, they must be a ‘Practising Member’ of Speech Pathology Australia.
3.3 Who can claim MBS items 135 and 289?
MBS items 135 and 289 are only available for consultant physicians practising in their specialty of paediatrics or psychiatry. If any other practitioner or specialist is required to review a child’s treatment and management plan, they will only be able to do so under an existing MBS attendance item. They cannot use MBS item 135 or 289.Top of page

3.4 How will the allied health services be allocated between the different providers?
It is the responsibility of the referring paediatrician or psychiatrist to allocate services to allied health providers in accordance with the child’s individual needs, as outlined in the treatment and management plan.

3.5 What is a course of treatment?
For the purpose of treatment services, a course of treatment will consist of the number of services stated on the child’s referral (up to a maximum of 10). This enables the referring practitioner to consider a report from the allied health professional/s about the services provided to the child, and the need for further treatment.

3.6 What are the reporting requirements for allied health providers?
A written report must be provided to the referring paediatrician or psychiatrist by the allied health provider/s after the autism/PDD assessment services have been provided.

On completion of the course of treatment, the eligible allied health provider must provide a written report to the referring paediatrician or psychiatrist which includes information on:
  • treatment provided;
  • recommendations on future management of the child’s autism/PDD; and
  • any advice provided to third parties (eg. parents, schools).
A written report must also be provided to the referring paediatrician or psychiatrist at the completion of any subsequent course/s of treatment provided to the child.

3.7 Can a child who has an incomplete treatment and management plan created by one practitioner have the plan ‘finished’ by another practitioner?
If the service was incomplete and an item other than MBS item 135 or item 289 was claimed by the initial practitioner, then the treating paediatrician or psychiatrist, who completes the diagnosis and prepares the treatment and management plan, can claim MBS items 135 or 289. The paediatrician or psychiatrist can contact Medicare on 132 150 for information regarding previous claims for the child.

Only one autism treatment and management plan can be prepared for a child in their lifetime. However, if a child sees a different medical practitioner to the one who prepared the treatment and management plan, the consultant paediatrician or psychiatrist who is seen subsequently can refer the child for any remaining allied health treatment services that are available to the child. Additionally, if there is need for a review of the plan at a later stage, this can be undertaken through other existing MBS consultation items.

3.8 What do paediatricians and psychiatrists needs to consider in developing a treatment and management plan?
It is advisable before using MBS items 135 or 289 that practitioners familiarise themselves with the DSM-5 classification of PDD in establishing the diagnosis and conducting the assessment of the child.

For the management plan, a risk assessment, mentioned in the item descriptors, involves assessment of the risk of a contributing co-morbidity as well as environmental, physical, social and emotional risk factors to the child or to others. The need for medication should also be considered where appropriate.

If the child’s care needs do not require a treatment and management plan, treatment can be provided under existing attendance items for the paediatrician or psychiatrist.Top of page

Part 4 – Referral Pathways

4.1 Does a paediatrician or psychiatrist need a GP (or any medical practitioner) referral to claim MBS items 135 and 28?
Yes. It is a requirement of these MBS items to have a referral from a GP or any other medical practitioner. If a paediatrician or psychiatrist has a current referral from a GP, they can claim MBS item 135 or 289 for the child.

4.2 Who can refer my child for allied health services?
A referral from a paediatrician (using MBS items 110 to 131) or psychiatrist (using MBS items 296 to 370 – excluding item 359) is required to receive allied health assessment services (MBS items 82000, 82005, 82010 and 82030).
A referral from a paediatrician (using MBS item 135) or psychiatrist (using MBS item 289) is required to receive allied health treatment services (MBS items 82015, 82020, 82025 and 82035).

4.3 Can referrals for services be made from the public health system?
A medical practitioner working in the public health system can make a referral to a paediatrician or psychiatrist who subsequently claims a Medicare service in connection with the referral. However, paediatricians and psychiatrists working in the public health system are not able to refer patients to allied health professionals for the purpose of accessing the MBS items.

4.4 Does a paediatrician or psychiatrist need a new referral at each stage of an assessment that occurs over a number of visits?
No. A referral is specific to a single course of treatment. This means that a new referral is not required in the progression of a staged assessment, providing it is for the same condition. If it is a separate course of treatment a new referral may be needed.

4.5 If the paediatrician or psychiatrist is confident with the diagnosis and claims MBS item 135 or 289 for the initial consultation with a new child, does the child forego the right to claim the four (4) allied health items for diagnosis?
The allied health professional assessment items (MBS items 82000, 82005, 82010 and 82030) cannot be claimed from MBS item 135 or 289. They can only be claimed from MBS items 110 to 131 or 296 to 370 (excluding MBS item 359).
Therefore, MBS item 135 or item 289 should only be billed once the paediatrician or psychiatrist has received all the information necessary to form a diagnosis and develop a treatment and management plan.

4.6 Will the child be required to obtain a new diagnosis to access allied health treatment items?
Yes. There may be occasions where a child has been diagnosed with autism/PDD prior to the introduction of the HCWA program Medicare items on 1 July 2008. In addition, there may be situations where, after 1 July 2008, a diagnosis is made by a practitioner who does not claim a relevant MBS item. For example, the practitioner may be working in the public system and therefore is unable to claim an MBS item.

Either MBS item 135 or 289 must have been claimed prior to a child accessing allied health treatment services. The requirement ensures that a child has a current and appropriate treatment and management plan for his/her condition, so that each child will get the maximum benefit from the MBS items.

4.7 Can a paediatrician or psychiatrist, using MBS item 110 or 296, refer a child to a new allied health item to assist with diagnosis and then use MBS item 116 or 304 to 318 to review the child and refer them to another new allied health service until the limit of four (4) is reached?
Yes. Given the complexity involved in the assessment and diagnosis of children with autism/PDD, this practice is allowed under the HCWA program.

4.8 What items are available to a paediatrician or psychiatrist to review a child’s condition after a treatment and management plan has been developed under MBS item 135 or 289?
Subsequent attendances to review the child’s condition and the outcomes of the treatment and management plan can be billed under the existing attendance items (MBS items 116 to 131 or 296 to 370, excluding MBS item 359), as appropriate.

4.9 What provisions exist for a child who has a treatment and management plan developed under MBS item 135 or item 289 and moves to a new locality, thereby preventing access to the allied health practitioners named in the plan?
In this situation, the child may receive a referral to a new paediatrician or psychiatrist who may review the treatment and management plan and refer the child to allied health providers in the new area. However, the child will still only be eligible for a total of twenty (20) treatment services in their lifetime.Top of page

4.10 Does a child need separate referrals for different allied health providers?
Yes. A child requires a separate referral for each allied health professional they receive services from. However, when an allied health professional completes a course of treatment (10 treatment services) and further services are allowed under the current referral, consultation with the referring practitioner to confirm the services should be continued, is acceptable. The allied health professional must also prepare a written report for the referring practitioner on completion of a course of treatment.

Part 5 – Medicare Services

5.1 What is an assessment service?
Assessment services are provided by audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists (MBS items 82000, 82005, 82010, 82030) for the purpose of assisting the referring paediatrician or psychiatrist with their diagnosis of the child, and for contributing to the child’s autism/PDD treatment and management plan. To claim Medicare rebates on assessment services the service must be: provided to a child who is not in a hospital; it must be provided to the child individually; the service must last at least 50 minutes; and the service must be provided before the child’s 13th birthday.

5.2 How many assessment services can my child have?
Each eligible child is entitled to up to a total of four (4) assessment services per lifetime. The four (4) services may consist of any combination of eligible allied health providers. It is the responsibility of the referring paediatrician or psychiatrist to allocate these services in keeping with the child’s individual needs and to refer the child to the appropriate allied health professionals accordingly. These services must be provided before the child’s 13th birthday.

5.3 Who can provide assessment services?
Assessment services can be provided by audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists, using MBS items 82000, 82005, 82010 or 82030, after referral from a paediatrician or psychiatrist.

5.4 What is a treatment service?
Treatment services are provided by audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists (MBS items 82015, 82020, 82025, 82035) to a child consistent with the treatment and management plan provided by the referring GP. To claim Medicare rebates on treatment services the service must: be provided to a child who is not in a hospital; be provided to the child individually; of at least 30 minutes duration, and be provided before the child’s 15th birthday, provided the treatment and management plan was in place before the child’s 13th birthday.

5.5 How many treatment services can my child have?
Each eligible child is entitled to up to a total of twenty (20) treatment services in their lifetime. The twenty (20) services may consist of any combination of eligible allied health providers. It is the responsibility of the referring paediatrician or psychiatrist to allocate these services in keeping with the child’s individual needs and to refer the child to the appropriate allied health professionals accordingly. These services must be provided before the child’s 15th birthday.

5.6 Who can provide treatment services?
Treatment services can be provided by audiologists, occupational therapists, optometrists, orthoptists, physiotherapists, psychologists and speech pathologists, using items 82015, 82020, 82025 or 82035, after referral from a paediatrician (using item 135) or psychiatrist (using item 289).

5.7 Can an autism/PDD service be provided to a child and then followed up with another autism/PDD service immediately after the first session?
The HCWA program allows multiple attendances for the same child on the same day. A child may have up to four (4) treatment services per day from the same (or different) allied health professionals.

5.8 Where can I find more information about the HCWA program medical practitioner and allied health items?
Information about all the HCWA MBS items, including schedule fee, Medicare rebates, item descriptors and explanatory notes are available at: MBS Online. Top of page

5.9 Are there any MBS items for pathology, dietary advice or specific biomedical treatments?
No. The autism/PDD items provide only for services that are consistent with research and best practice guidelines. In 2006 Roberts conducted a literature review to identify the most effective models of practice in early intervention of children with autism spectrum disorders. The review does not recommend the use of biomedical and naturopathic treatments, due to the lack of appropriate evidence to date to assess the long term effectiveness and potential side effects of these treatments.

Part 6 – Other Initiatives and Further Information

6.1 Can my child access the ‘Chronic Disease Management’ items as well as the HCWA program?
Yes, provided your child meets the necessary requirements for both programs. To be eligible to use the Chronic Disease Management (CDM) MBS items, patients must have a chronic (or terminal) medical condition and complex care needs that are being managed by their GP under a GP Management Plan (MBS item 721) and Team Care Arrangements (MBS item 723). Once these MBS items are in place, patients are able to be referred by their GP for up to a total of five (5) Medicare rebateable allied health services each calendar year.

Eligible allied health services can be provided by Aboriginal health workers, audiologists, diabetes educators, chiropractors, dietitians, exercise physiologists, mental health workers, occupational therapists, osteopaths, physiotherapists, podiatrists, psychologists, and speech pathologists.Top of page

6.2 Can my child access the Better Access items as well as the HCWA program?
Autism/PDD is generally regarded as being a developmental disorder rather than a mental health disorder. However, if your child is diagnosed by a GP as having a mental health condition, they may be eligible to receive services under the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative. Children, on referral by a GP who is managing the child’s condition under a GP Mental Health Treatment Plan, or on referral by a psychiatrist or paediatrician, may be eligible for Medicare benefits in respect of up to a total of 10 allied health services per calendar year.

Eligible allied health services can be provided by psychologists, occupational therapists and social workers.

6.3 Can children with learning disorders access any autism/PDD items for direct instruction programs that have been demonstrated to improve reading skills?
PDD Medicare items were introduced only for children with autism/PDD. If the child’s learning disorder is autism/PDD related, he/she can access Medicare rebates for appropriate treatment provided by eligible allied health professionals. Links to information and services for children with learning disabilities are provided at the Department of Social Services (DSS) website.

6.4 Do the out of pocket expenses count towards the Medicare Safety Net?
Charges in excess of the Medicare benefit for these items are the responsibility of the child’s parent. Some out-of-pocket costs will count towards the Medicare safety net for that child. Any allied health autism/PDD assessment services that are in excess of the maximum of four (4), and any allied health treatment services that are in excess of the maximum of twenty (20) allowable per child per lifetime, will not attract a Medicare benefit and the Medicare Safety Net arrangements will not apply to costs incurred by the child for such services.

6.5 Where can I access information about the $12,000 early intervention funding?
DSS is administering this component of the HCWA program.
To find out more about the early intervention funding visit: Early Intervention Services for Children with Disability on the Department of Social Services Disability and Carers web page.

6.6 How can I find out how much of the original $12,000 early intervention funding is left?
Family Activity Statements (FAS) are sent to families registered for the HCWA program on a monthly basis, providing there has been expenditure out of their allocated funding in that month. The FAS provides the remaining early intervention funding balance for each child.

Service providers are required to check the family’s early intervention funding balance on FOFMS (DSS Online Funding Management System) each time a family comes for a service to ensure they have funds available.

Families also need to be mindful of the fact that there is a time lag between a service received and the fee being claimed for that service by a provider, therefore any current balance may not include all the services a family has used. Service providers are required to claim fees from DSS within 28 days of the service being provided. Families are advised to track their own expenditure too.

Families can contact DSS on 1800 778 581 or by email to check their funding balances.Top of page

6.7 How will the transition from HCWA to the National Disability Insurance Scheme (NDIS) affect my child?
HCWA early intervention support will progressively transition to the NDIS but will continue to operate outside of NDIS sites until full roll out of the scheme.

Once eligible children have an approved NDIS support plan in place, their access to HCWA early intervention funding ceases, at which time they will be able to access support through their NDIS support plan. Access to HCWA ceases only once the child has an approved plan in place. This arrangement ensures continuity of service.

The support that is provided by the NDIS is based on each child’s individual needs. Unlike HCWA, the NDIS delivers a long term approach to support and will be a significant improvement on the way disability services are currently delivered.

Some of your questions about the transition of HCWA to the NDIS may be answered on the Factsheet: Helping Children with Autism package on the NDIS website.

6.8 Does the transition from HCWA to the NDIS happen automatically?
No. Parents are required to register their child to determine if the child is eligible for the NDIS. If you wish to register your child for the NDIS, or find out whether you are able to register for the NDIS in your area, please contact the National Disability Insurance Agency on 1800 800 110.