WHAT IS AN EPC?
The Enhanced Primary Care (EPC) plan was introduced over 20 years ago to help people reduce the costs of their allied health services utilising the Medicare system. It was designed to help people with chronic health conditions access Physiotherapy and other allied health providers.
It was actually removed from the Medicare Benefits Schedule (MBS) in 2005 and is now referred to as the Chronic Disease Management plan (CDM). However, most people still refer to the plans as EPC's -often even your GP.
HOW DO I QUALIFY FOR A CDM plan?
The CDM plan was introduced to help create a plan of management for people with chronic or terminal conditions. These conditions will generally have been present for 6 months or more. The CDM plan assist people who require multidisciplinary, team-based care from a GP and at least two other health or care providers using a Team Care Arrangement (TCA). The following allied health professionals are eligible to provide services under Medicare (TCA) for patients with a chronic or terminal medical condition and complex care
- Aboriginal and Torres Strait Islander health practitioners
- Aboriginal health workers
- Diabetes educators
- Exercise physiologists
- Mental health workers
- Occupational therapists
- Speech pathologists
Some of conditions that qualify for a CDM plan might include:
- heart problems
- stroke, diabetes
- chronic pain
- chronic joint or muscular issues.
There is no set list of eligible conditions as this will be determined by your GP under guidance of the MBS.
HOW MANY VISITS WILL IT COVER?
The total number of visits you can receive for all allied health providers is five visits each calendar year. These five visits might be assigned between different practitioners or all might be assigned to just one allied health profession. This will be determined by you and your GP depending on your particular needs.
The five visits each have their own Medicare codes. You can only use these particular codes 5 times per calendar year across all different allied health providers. The visits can only be used for 1:1 treatment and are not to be used for group treatment sessions (except for type 2 diabetes groups).
Group services are available for the management of type 2 diabetes if conducted by an accredited Exercise Physiologist.
- you must have been assessed as suitable by your GP
- the service is provided is for groups of between 2-12 people
- the group duration is 60 mins
- a report is completed at the end of the program
- there is a maxium of 8 sessions per calendar year
'MY GP SAID THAT I WOULD GET 5 FREE VISITS'
The most common misconception about the TCA process is that it is totally free but this isn’t quite true. It is the same situation as bulk-billing. Some GPs bulk bill but most charge a gap these days as the rebate is not sufficient for most health services to make ends meet..
Some Allied health practitioners may not charge a gap fee so its always a good idea to check this when you call. At In-Balance we do charge a gap fee, so the decision is up to you as to whether you want to see one of our fabulous physios and pay a gap, or see another physio elsewhere who may do "rebate only" treatment.
One way of looking at it is that the rebate amount for Medicare is usually larger than a private health insurance rebate, so whilst not free, it is still good value when you consider the cost of private health Insurance premiums.
NB: if you have reached the Medicare Safety Net level for the year because you have paid a lot of out of pocket costs, the rebate goes up significantly, so the gap would be minimal.
WHAT IF I WANT TO SEE A DIFFERENT PHYSIO THAN THE ONE WRITTEN ON THE REFERRAL?
If your TCA referral has a different practice name on it, you will need to get a new one from your GP. If it is a different physio but within In-Balance, that is fine as long as the form has our practice name on it.
If the form doesn’t specify the name of the practitioner or the practice but just the allied health profession, then you can see anyone of that profession as long as they are registered with Medicare. The allied health practitioner will write to your GP after your first and last visit and let them know of your progress.
CAN I USE MEDICARE FOR PHYSIO, PODIATRY, EP AND OCCUPATIONAL THERAPY TREATMENT?
You can only access Medicare with a CDM plan and a TCA referral to a the specific health professional. If you don’t qualify for a CDM plan, or if you have used up your 5 allied health visits in the calendar year, you will have to wait until the next calendar year to have it renewed by your GP.
You can of course still attend for treatment at In-Balance but you will need to cover the consult costs fully. If you have private health insurance you can still use this to claim a rebate but you can only use one or the other not both private health and medicare rebates.
HOW DOES THE MEDICARE REBATE PROCESS ACTUALLY WORK?
If you have a valid CDM plan and TCA referral, you are responsible for paying the full amount at the time of your appointment. If you would like to receive the rebate into your account, this can be done at the time of the consult via the HICAPS terminal), but this can only be done with a debit card.
Unlike with a GP visit, Medicare doesnt pay the rebate into a credit account for allied health services. If you do not have a savings/debit card then the paperwork is sent to Medicare and processed manually into their account listed with Medicare (via BSB and Acct number). This can take up to 28 days.tr