Chronic Disease Management Plan
A guide for doctors and patients
As per the Medicare website;
A chronic medical condition is one that has been, or is likely to be, present for at least 6 months or is terminal.
A chronic medical condition is one that has been, or is likely to be, present for at least 6 months or is terminal.
WHAT ARE THE CHRONIC DISEASE MANAGEMENT MEDICARE ITEMS?
The chronic disease management (CDM) Medicare items are part of a Government initiative that assists people living with a chronic and/or complex medical illness. Medicare rebates are available for treatment from allied health professionals who are assisting in managing the illness. A GP is required to prepare a management plan (called a GP Management Plan and Team Care Arrangements) for a patient so that their illness can be better managed with the assistance of allied health professionals. The initiative allows a person with a complex and/or chronic illness to claim a Medicare rebate for up to five visits (in total) to certain allied health professionals within a calendar year. Better Health Nutrition & Fitness, provide eligible services for this care plan:
- Dietitian (Diet management, weight loss and treatment of medical conditions)
- Exercise Physiology (Weight loss through exercise interventions, and treatment of chronic health conditions)
- Physiotherapy (Injury management, rehabilitation, dry needling, clinical pilates and manual therapy)
Chronic medical conditions that may be covered by the scheme must have been present, or are likely to be present, for six months or more. The conditions include, but are not limited to:
- Asthma
- Cancer
- Cardiovascular illness
- Diabetes
- Musculoskeletal conditions
- Stroke
- Morbid Obesity
WHAT ABOUT MY PRIVATE HEALTH INSURANCE?
You cannot use your private health insurance ancillary cover to top up the Medicare rebates for these services. You need to decide if you will use Medicare or your private health insurance ancillary cover to pay for Allied Health services you receive. You can either access rebates from Medicare by following the claiming process or claim where available on your insurer’s ancillary benefits.
HOW MANY SESSIONS WITH A BETTER HEALTH NUTRITION & FITNESS PROFESSIONAL AM I ENTITLED TO?
The chronic disease management scheme only provides payment for a total number of five visits per calendar year to all allied health professionals that are specified in your Team Care Arrangements (TCA) that your GP has prepared. This means the number of sessions with one of our AHP's that will be paid for by Medicare under this scheme will depend on how many sessions with other Allied Health Professionals you have had or will require. For example, your TCA may state that you need two sessions with a Podiatrist, one with a Physiotherapist, one session with a Dietitian, and one session with an Exercise Physiologist. The combination of services can only add up to five sessions in a year, otherwise you will be required to pay privately for any additional services.
The referral is completed by your GP in conjunction with a CDM nurse. It is not a standard 5-10 minute consultation. A properly conducted care plan would require a 30 minute consultation. Check with your medical centre when booking your appointment. A team care arrangement must include a minimum of 2 other providers delivering different services outside of the GP.
- Dietitian
- Exercise Physiologist
- Podiatrist
- Diabetes Educator
Medicare prefer oral communication in regards to the CDM plan, however it is still acceptable to complete offer and acceptance via fax or secure email communication.
CAN A PATIENT SEE A PRACTITIONER OTHER THAN THE ONE SPECIFIED ON THE REFERRAL FORM?
If the patient’s referral form contains the name and practice address of an allied health professional they can see any allied health professional at that practice. However, if a patient’s referral form contains the name of an allied health professional, but no practice location, they must see the allied health professional who is specified on the form or else obtain a new referral form from their GP. If the GP has only specified the type of allied health professional, the patient is free to see any allied health professional of their choosing as long as they are registered with Medicare Australia to provide services.
This information has been obtained from the Medicare website which outlines the requirements for referral under this program.
Further Information for Referring Practitioners
OFFER AND ACCEPTANCE OF CARE PLAN
Oral Communication: The referring GP or nurse will call the clinic to discuss offer and acceptance. This would then be documented in writing. The oral communication must include advice on treatment and management of the patient.
A blanket agreement (a general agreement for a referring practitioner to refer all their patients but would not send individualized offer and acceptances) to participate in TCA’s would not be sufficient.
A fax form by itself would not meet the requirement for collaboration, if it does not include the treatment or services to be provided by the provider, matched to the specific needs of the patient.
REFERRAL VALIDITY
For the Chronic Disease Management Program, a Medicare referral is valid for a calendar year. Any individual can be allocated a maximum of five individual services each calendar year. More services in a calendar year are not available under any circumstances. A calendar year is defined as the period of time between January 1 and December 31.
Example: If a patient is given a referral to see a Dietitian for three sessions in November, they only have until December 31 to use those sessions. That same patient would then be eligible for up to five more sessions with an Allied Health Professional as of January 1 the following year. **Doctors please note that allocated session expiry follows different conditions versus the 721/723 expiry conditions which is valid for one year from the date of issue of the referral**
If the services are not used during the calendar year in which the patient is referred, the unused services may be used in the next calendar year. However, they will be counted as part of the five allied health services available to the patient during that NEW calendar year. A person cannot accrue sessions and add them on to the new five for the following 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 care plan, they need to obtain a new referral form from their GP.
Oral Communication: The referring GP or nurse will call the clinic to discuss offer and acceptance. This would then be documented in writing. The oral communication must include advice on treatment and management of the patient.
A blanket agreement (a general agreement for a referring practitioner to refer all their patients but would not send individualized offer and acceptances) to participate in TCA’s would not be sufficient.
A fax form by itself would not meet the requirement for collaboration, if it does not include the treatment or services to be provided by the provider, matched to the specific needs of the patient.
REFERRAL VALIDITY
For the Chronic Disease Management Program, a Medicare referral is valid for a calendar year. Any individual can be allocated a maximum of five individual services each calendar year. More services in a calendar year are not available under any circumstances. A calendar year is defined as the period of time between January 1 and December 31.
Example: If a patient is given a referral to see a Dietitian for three sessions in November, they only have until December 31 to use those sessions. That same patient would then be eligible for up to five more sessions with an Allied Health Professional as of January 1 the following year. **Doctors please note that allocated session expiry follows different conditions versus the 721/723 expiry conditions which is valid for one year from the date of issue of the referral**
If the services are not used during the calendar year in which the patient is referred, the unused services may be used in the next calendar year. However, they will be counted as part of the five allied health services available to the patient during that NEW calendar year. A person cannot accrue sessions and add them on to the new five for the following 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 care plan, they need to obtain a new referral form from their GP.