Chronic Disease Management - Individual Allied Health Services Under Medicare - Residential Aged Care Facilities

Fact sheet on Chronic Disease Individual Allied Health Services in Residential Aged Care Facilities Eligibility for Medicare Rebates

Page last updated: 01 July 2014

Chronic Disease Management - Individual Allied Health Services Under Medicare - Residential Aged Care Facilities (PDF 286 KB)

Residents of residential aged care facilities (RACFs) can be eligible for Medicare rebates for up to five individual allied health services (Medicare Benefits Schedule [MBS] items 10950-10970) each calendar year, when a general practitioner (GP) has contributed to a multidisciplinary care plan prepared for the resident by the facility and referred them for allied health services under MBS item 731.

These services are available to patients with a chronic (or terminal) medical condition and complex care needs under the Medicare Chronic Disease Management (CDM) items.

Medicare Eligibility and Aged Care Funding Classification

Medicare-rebateable allied health services should not replace services that are expected to be provided to residents by the facility, as a requirement under the Aged Care Act 1997

Under this legislation, approved providers of residential aged care services are required to provide therapy services, such as recreational, speech therapy, podiatry, occupational therapy, and physiotherapy services, to certain residents (as defined by the resident's funding classification) at no additional cost.

The services to be provided are:

  • Maintenance therapy delivered by health professionals, or care staff as directed by health professionals, designed to maintain residents' levels of independence in activities of daily living; and
  • More intensive therapy delivered by health professionals, or care staff as directed by health professionals, on a temporary basis that is designed to allow residents to reach a level of independence at which maintenance therapy will meet their needs.
The provision of these services excludes the requirement to provide intensive, long-term rehabilitation services following, for example, serious illness or injury, surgery or trauma.

If residents are entitled to receive the allied health services noted above at no additional cost to themselves through the RACF, those residents should not routinely be referred for allied health services under Medicare.

If a GP or allied health provider is uncertain about whether a patient requires a service that should be provided by the RACF under the Aged Care Act 1997, rather than a service under Medicare, the GP or allied health provider should obtain clarification from the RACF.

Referrals

A GP and the RACF should work together to assess and plan the care and service needs of the resident.

However, the GP is responsible for identifying the need for allied health services and for making referrals.

It is inappropriate for allied health providers to partially complete referral forms for GPs to sign in a way that pre-empts the GP’s decision about the allocation of these Medicare services.

Ensuring Medicare requirements are met

The allied health services available through MBS item 731 are for patients with a chronic (or terminal) medical condition on referral from a GP and the following requirements must be met for a Medicare benefit to be payable:
  • The need for the allied health services must be identified in the patient’s multidisciplinary care plan.
  • The services must be provided to a patient individually and in person.
  • The services must be of at least 20 minutes duration.
GPs and allied health providers are responsible for ensuring they fulfil all the requirements of the Medicare items that they bill. This includes health providers who contract with a RACF to provide Medicare services.

If a health provider is concerned about a contractual arrangement impacting on their capacity to bill residents for items on the MBS, the provider should seek legal advice.

Further information

Detailed information about the Medicare CDM items and associated allied health services, including item descriptors and explanatory notes is available at MBS online.

Providers can call the Department of Human Services (DHS) on 132 150.

Patients can call DHS on 132 011.

Detailed guidance on approved provider care responsibilities is available in the Residents’ Rights Section of the Residential Care Manual.