30. Is Speech Therapy Covered by Medicare?

Episode Transcript

Welcome and Introduction

Welcome to Beyond Words by Pop Family. I’m Heidi and today I’m chatting with Pop Senior speech pathologist and clinical lead Monique. Mon is passionate about advocating for clients and helping families all over Australia to navigate complex systems.

Based in Adelaide, Mon graduated with a bachelor of speech pathology in 2016 and began her clinical career by working in the mental health, disability and public health sectors before joining the Pop team to provide telehealth speech pathology all over Australia.

Monique’s clinical interests include language and literacy development, neuro affirming practises, supporting individuals with selective mutism and trauma informed approaches to therapy. Monique provides supervision and training widely across the team here at Pop and her passion for advocating for the best outcomes for her clients is her single greatest attribute.

Mon is really knowledgeable and explains things simply and beautifully for parents. I can’t wait for you to hear what she has to say about accessing Medicare rebates today.

Welcome to Beyond Words Monique.

Thank you Heidi. Thanks for having me It’s lovely to see you just on a different platform to Zoom.

Medicare Chronic Condition Management Plan (GP CCMP)

So let’s talk about Medicare. What funding does Medicare give us for speech therapy and what’s it called? What’s this thing called?

So Medicare offers funding through what’s now called the GP Chronic Condition Management Plan or G-P-C-C-M-P, which is a mouthful in itself.

So under this plan you can access a rebate for up to five allied health sessions per year and that can include speech pathology and the rebate is currently $61 a session, which doesn’t cover the full cost but does reduce the out-of-pocket fee that is required when accessing speech pathology appointments.

And that’s a really important fact too. We’re not talking about prices of speech pathology today, but we do need to follow up with that in a different episode because that’s something people really want to know about.

Roughly though, how much does that get you off a standard session? Like a standard one hour session?

Probably just over a quarter. It’ll probably cover about a quarter, maybe slightly more of a one hour session.

Okay, that’s really good to know. So it’s not covering the full fee,

It does not cover the full fee. No. But it does help alleviate some of the out-of-pocket costs.

Absolutely, it sort of works a little bit similarly to the way that private health works in that way. It doesn’t quite often cover the full fee, but it alleviates that.

Okay. Yeah, great to know. So they used to be called GMPs, which was, or CDMPs. They’ve changed a few times. So we’ve got this new terminology. Good to know.

Medicare vs. NDIS Funding

I would love know from you what the difference is between Medicare funding and NDIS funding. If I’m a parent, I’m new to navigating this system. I think like why are there all these different schemes and what’s the difference? These are probably two of the biggest players that the government provides rebates for. What’s the difference between Medicare and NDIS funding?

So Medicare and NDIS are actually two separate systems. Medicare is very limited in terms of the fact that it’s essentially covers a small rebate for a handful of sessions each year. Whereas the NDIS, which is the National Disability Insurance Scheme, on the other hand, can fund much more intensive ongoing therapy if your child or you as an adult meets their criteria.

So Medicare is more like a top up or a way to kind of get started or if you’re not eligible for NDIS, while NDIS is for longer term lifelong permanent support.

– Yes. So that’s a really, really lovely simple way of saying it.

If I’m on the NDIS scheme, can I access Medicare funding?

Yes, you can access both but you’re not able to claim them at the same time for the same appointment service?

No double dipping.

No double dipping. Exactly because then that would be a duplication of funding.

Medicare is actually for everyone. There’s still a criteria, but the criteria is at a lower bar essentially than the NDIS. The NDIS You need to have a lot more requirements to fit the criteria for NDIS. But Medicare essentially has a lower bar.

Maybe if I’m to give an example, I have a child, oh well I have a child, she is three and a half and I’m hypothetically worried about her speech sounds and I think, oh I just don’t think that they’re right. I can’t understand her all the time. She certainly doesn’t have a severe speech issue. So she may not, I’m not thinking about the NDIS right now, but maybe I’d go to my GP and maybe I’d talk about accessing some Medicare funding to get her checked out.

So essentially it’s called a chronic disease management plan because you need to have had at least six months of something affecting you to be able to access it for it to be chronic.

Okay. So need to be chronic, it needs to be chronic. It doesn’t necessarily need to be lifelong, which can be the differentiating factor between you know, accessing NDIS, especially over the age of seven when you need an ongoing disability. Whereas for children under the age of seven, within NDIS, they can access early intervention support. But for the Medicare funding, it is for needing at least six months of it affecting you.

Yes. And do you know what lots of kids actually have the, for example, like you had a stutter up for six months. We actually, that’s one of the criteria. If you’ve had it for six months, then you should be coming in.

Yes.

Essentially. Yeah. Same with speech. Yep. That’s the sign for a stuttering for example. If you’ve been doing that, then that’s a sign that it is chronic perhaps and you need to come and see a speechie for that.

Okay, wonderful.

CCMP Eligibility for Adults and Other Allied Health

So we’ve talked about a few things there about Medicare and NDIS and we’re not jumping into NDIS today. So I want to know, walking myself through this, I’m a parent. I also want to know like what about me, what if I think I have a chronic condition?

So you as an adult are also eligible to be able to apply for the Medicare chronic condition management plan.

Okay.

So it’s not just exclusively for children, it can be for adults too.

It can be, and it’s not exclusively for speech pathology either.

Correct. And you can access All Allied Health under this scheme.

Yep. And who are they?

Occupational therapy, psychology, podiatry, physiotherapy, dietitian, social work. I think I’m missing a couple.

We surely are, but we, we didn’t come in to talk about them. We’re talking about speech therapy but because that’s what we know about that you can, for example, I, I talk professionally for a living. I am not worried about my speech at the moment. I’m not worried about my language or the others, swallowing or eating or the other things that speech therapists can do. But as an adult I might be listening to this and thinking actually I’ve got a mobility issue or I’ve got something where I could actually go to my GP.

So this is actually not just for moms and kids, it’s it’s for adults and maybe you could, maybe you could prompt your parents or someone that you know who needs support to let them know that they can actually access this funding too.

Correct. So it’s still a total of five sessions per calendar year. So if you do go with multiple therapists or allied health, you can divvy it up how you wish. So that might be, for example, two sessions spent on a speech pathologist, three spent on an occupational therapist or four spent on a speech pathologist and one spent on a psychologist. So you can kind of choose how you wish to use it. Yeah. Which is really nice because that allows for you to individualise your chronic disease management plan.

Great. You get a bit more choice in autonomy.

Yeah, we love that.

Getting a Referral and Preparing for the GP

Okay, so I’ve decided, I’m now back to being my hypothetical parent with my child. I’ve decided like maybe I need to be seeing a speech pathologist like maybe this issue has been going on for six months. Do I need a referral? Like how do I, do I need a referral to see a speech therapist in the first place?

No. So you actually don’t need a referral to see a speech pathologist. You can call us directly or call a provider directly and book in. But if you do want to claim the Medicare rebate, that’s when you need a referral form from your GP under the GP chronic condition management plan. And this is the same whether you’re an adult or arranging support for your child.

Yeah. Beautiful.

So the reason that we get a referral, you can actually call up and like, ’cause if you think that they’ve got a waiting list who, whoever your local provider is, you can actually call up and book in and you don’t actually need to have the chronic condition management plan until the day of your session. So you could call up and get booked in and you could actually get that chronic condition management plan as long as you’ve got it before your session you can still claim

Correct.

And even if you decide to pay out of pocket for your first session but then it kicks in in your next subsequent session, that’s fine too. There’s flexibility within that around how you use it. Especially when you’re going with a private provider of course.

Okay. So I need to go to the GP, I want to get my money back, I want to get my $61, what is it?

$61.80

I want to get my $61.80 back. That’s a lot of money I need to prepare. Like what am I taking to the, am I going to go to the GP and they give me all the answers?

No, not necessarily. I would say preparation definitely makes the whole process easier. So just a couple of ideas of things to bring would be a short summary of your child’s needs or any diagnoses if they meet any diagnoses, any recent reports from schools or previous therapy reports if you have that. And a list of current support your child is receiving. And definitely you need some information from previous specialists or doctors appointments as well because all of that will help.

But definitely we’ve created a resource here where this can include key questions to ask and what to bring for your GP session to be able to make this process a bit more streamlined.

One of the hardest things about being a parent and navigating a health issue for your child. Like my daughter has eczema, you know, you wouldn’t think that a rash could cause so much stress and anxiety in your life. And I’m a health professional and I own a health company and I navigate the health system as my core business and I still find it exhausting and overwhelming to have to advocate for my child in an industry that I’m very comfortable in. So I just can’t imagine how difficult it is for parents who have no experience like working in hospitals with doctors, with you know, within the system we call it.

So essentially something like this could just be really amazing if we’re going to get ready for the GP, this resource can really take us through it. So it sort of summarises what you just said, doesn’t it? What to bring to your GP appointment then we’ve got, oh let’s talk about this.

How Pop Can Help

How can Pop help? So some of the things that we can help support you with through our discovery call is where you can sit down with a speech pathologist and really go through all of your concerns and some signs that you, we might look out for when we are thinking about our child and what they may need.

It could be your child’s speech is hard for you or others to understand. It could be that they’re late to start talking or they have a very small vocabulary compared to their peers. They might struggle to follow instructions or answer questions and join in conversations. They may be school age and they’re struggling with reading, writing, and spelling and social communication could also be something that they notice when interacting with other children of the same age. For example, you know their ability to make friends and take turns and understand jokes.

So if you’re noticing any of these things, it’s worth checking in with a speech pathologist early and really going through and using that time to discuss your concerns and work out is speech therapy the pathway that I need to go down and if it is, what information can I bring to the GP to help support that?

And one of those things can be our summary from our discovery calls, which will have some of that information outlined that has been corroborated by the speech pathologist as well.

That’s right. We have a group of experienced speech pathologists who enter the answer the phones on our discovery calls. You can talk to them for 15 minutes and basically get a pretty clear idea of whether your child is meeting milestones or whether they might be behind or not. And you can take that as evidence to your GP to apply for Medicare funding.

There is also another resource here we’ve just linked in the Speech Pathology Australia milestones, which are, so you can have a look at whether your child is hitting those developmental milestones. They’re mainly for speech and language. I’m not sure if there are feeding milestones on that one.

I’m not sure. I don’t believe so. I believe those are communication milestones up until the age of about five to six. Yes.

Yeah. But there are different, you know, by Googling or different resources online as well as checking in with the teacher. Especially if they’re school age and they’re above the age of six and you’re trying to work out, I guess what’s typical of that age group touching base with teachers having a chat with our speech pathologists, talking with your friends, that can really help as well.

Using the GP Checklist

So we’ve got our evidence and we are going to the GP what’s here on our GP checklist so we can print this off. Well I’m a mom, I’m going to the GP, I can print this off and I can actually take it with me because my number one tip to moms, honestly when I’m going to the doc, when I’m got, and I’ve had so many appointments lately, we’ve got two children, two children and a husband and you manage all of the appointments. There is a lot and like I write a list so this is, and I ask every single question and then at the end of the appointment I go, just wait a minute and I make sure I’ve answered every single question.

So this is essentially the resource that our parents can take with them to the GP?

Yes And they can, yeah and they can use it to go through it with the GP directly so that way they ensure that all their questions are being answered, the GP has the, that they need and all the information is set up on the referral.

Beautiful. So that actually, because sometimes the GP has all the best intentions but if they miss just one piece of information on that referral then you can’t get the rebate

Correct.

It can delay it or it can make the kind of back and forth admin process a bit more time consuming for then your child to be able to access that support and jump and use that rebate for that appointment.

So in summary, if you have this checklist, it’s going to really help you prepare for your GP appointment where you are requesting Medicare funding. It’s going to give you a really good idea of whether you’re eligible or not because it allows you to actually investigate your eligibility for speech pathology. Obviously we are not putting out eligibility for other allied health services on there. That’s not what we do. We only do speech therapy.

If you are still a little bit unsure about your eligibility, you can call us for a discovery call and probably find out.

Yes, correct.

And if you don’t have a certain answer of course from us we can’t, we are not doctors so we don’t give the sign off, we don’t give certainty but we can write down our opinion and you can take that with you along with this checklist as evidence to take to the GP. And also if you’re a GP, that is a fantastic thing for a patient to turn up with. Here’s the documentation, what do you think of it essentially?

– Correct.
– So okay I decide my child needs speech therapy, I want to apply for the Medicare rebate, how do I do it? I’ve got my papers, I’m going to walk into the office, what goes on?

So really step one is booking an appointment with your GP. Bring along your concerns and our checklist and go through it with them. If your GP agrees that your child has ongoing needs and they meet eligibility for the chronic condition management plan and include a referral to a speech pathologist, you can then book in with us, bring the referral letter and then after each session you can claim the Medicare rebate either on the spot or through Medicare directly.

Okay. On the spot as in straight after that session?

Yeah, on the spot as in they pay for the session then we put through the invoice through to Medicare and then Medicare will reimburse you and pop it back into your account. Yeah. And Then put through back to our like straight to your card that you’ve got in the Medicare app or whatever, don’t they?

Correct. Yes, that’s correct.

And I don’t think, I’m pretty sure it usually takes like a business day, it’s pretty a quick turnaround for the reimbursement to be received. Because I have my Medicare set up or my old personal card that’s just mine. So every time I have an appointment it’s kind of like I’m making money because it’s not in my, it’s not in my joint family.

– Your joint.
– Yeah.

Oh I’ve, I’ve got $60 or I have a few appointments, I’ve got a hundred bucks in there. You know, anyway, it’s a real win to get that money back and it makes a huge difference sometimes.

– Okay, definitely.

Duration of Therapy and Other Funding Schemes

So In your experience, in your clinical experience you are, I’m not currently clinical, I’m in my early little baby motherhood era so I’m not, I haven’t used this new Medicare scheme since the changes happened in July. So in your clinical experience so far does, you know it’s, say you need speech therapy, your GP gives you the five sessions and the $61 for each one, how far does that go if you want to get results from speech therapy

At Pop the average child would need more than five sessions to make meaningful progress. I think for many children, therapy tends to run weekly or fortnightly over months and even years for some. Medicare will cover five sessions per year. But research does show that it takes often 20 to 30 minute sessions or more for children to reach their goals over at least a six month period. But that really depends on the type and severity of their needs. So Medicare is a really helpful start but most families may need to use private health insurance NDIS or private payment to continue therapy over that longer period.

Yeah. Our average length of a client at POP is around 24 sessions. Around six months.

Yeah, around six months Of weekly therapy as well.

Correct. And not everyone who leaves our service is actually achieved all their goals. Either, you know, people still got to leave ’cause they’ve run out of money or because they’ve, they’ve moved or their situation has changed or their schedule has changed. All of those sorts of things cause people to cease therapy as well. It’s not because you’ve just achieved everything.

So especially if you do have a chronic condition, if you actually have a chronic condition, six months might, I would be really impress if you’ve achieved all your goals in six months.

Yeah, that and that’s, you know, and that’s when we likely see, you know we look at exploring maybe does NDIS or another system potentially cover that to be able to get that longer term support. The Medicare system is a great way for you to get started and really get in to see a speech pathologist and get that assessment and therapy started. It’s a great access point for that and to give that financial to alleviate that financial burden because that’s actually just one of the biggest gaps.

And I think that that’s why I think I want to ask about how does, there’s a different type of funding as well called helping children with autism. How does that fit into this scheme? Is that Medicare funding?

It is under Medicare but if a child is diagnosed with autism spectrum disorder by a specialist such as a paediatrician or a psychologist, they may be eligible for up to four sessions for assessment and then 20 sessions for therapy and that is at higher rebate of $87.25 per session. But these are separate from the chronic condition management plan that we’ve been talking about, because there is a stricter criteria for their diagnosis.

Yeah, yeah. And essentially that’s an additional, so you could hypothetically I’ve got my child, I’ve had concerns, I’ve gone to the GP, I’ve had an initial assessment through a speech pathologist and they’ve said oh I think we need to go to a paediatrician and then I could maybe use the helping children with autism once I do you have to, do you only get helping children with autism if you’ve got an autism diagnosis already?

Correct. Yes. Yeah you have to have had the diagnosis first to be able to be eligible for that.

Yeah. And we’re not delving into rebates for specialists or any lists like that today. So we’re just talking about speech pathology so.

Dealing with GP Familiarity with the New Scheme

Okay, interesting. Thank you very much. So the scheme has changed since July. What are we hearing from parents on the ground about this new process? Is it easy to get? Like what’s the activity that we are seeing and what are parents saying?

Yeah, I think families, from what I’ve been hearing, families are telling us the new system is a bit clearer than before but it can still be very confusing at times. I think the main challenge is making sure that GPs are on the same page about eligibility and some parents may find the paperwork really straightforward while others experience delays if their GP isn’t familiar with the process.

Which is another reason why taking our resource with you, our GP checklist could be really effective because you have no way of knowing if your GP has actually written one of these since the changes came out in July 25.

– Correct.
– So it’s also another reason why when choosing a GP choosing one that is likely specific to your needs. So if you’re an adult with mobility difficulties, like just calling up and making sure that your GP knows about that. GPs are generalists of course, but they do have special interest areas. So for me, hypothetical child who’s three, I would be looking for a GP who had a specific interest in child development and then they’re likely to maybe know about this scheme and they’ve probably written them for other children as well. So that’s just an important point I think.

Yeah because you know we are still seeing some inconsistencies across like how GPs are finding the the process. I mean some GPs are excellent and they get the paperwork right away whereas others are less familiar with the scheme or have like a different interpretation of what counts as a chronic condition.

So this is really why we recommend families bring our resource, bring our checklist. It will make it easier for the GP to see why a referral is needed and why we are making this request.

It’s an advocacy tool. It’s what to take advocate for yourself or your child in the GPs.

So let’s flip, have we found out how GPs are finding this process? Like is their backend because we want this to be easy for GPs. If parents know more about what the process is like for the GP, they’re likely to know what the motivation might be or how to make it easier. And I guess that’s why we’ve got this checklist. We’re trying to make it as easy as possible for the GP. Do we know how they’re finding the new system?

I think we’re still seeing a lot of inconsistencies because it really depends on the level of training and exposure the GP has had. And I know that Medicare are looking to provide more wider scale training so we can kind of get onto this universal changes in this system. But I think that’s still part of a bigger rollout plan.

– Yes. So because I am, hmm, what’s the word for me in this situation? I like to control situations. I would probably call my GP in advance. I’ll call the office and I would say, hi, I am going to come in and I’d like to talk about if my child’s eligible for this scheme. I just want to let the GP know that that’s what I’ll be asking about. Admin will send that message through to your GP. They’ll have time to, especially if you send it the week before your appointment, they’ll have time to read up on the scheme before you go in. So maybe that’s a good touch too. Especially if you’ve never met your GP before or the GP that you’re going in to meet. If you have a great relationship with that GP and you already know or they feel you know that they’re going to read up on it on the spot in front of you. Like my GP literally searches things in front of me so when she’s looking into something to interpret the information, she’s doing it in the room with me. And I feel like that’s, I feel really great in that environment. So if you’ve got that relationship then just go straight in there. But if you don’t know them you could always call in advance and let them know what’s coming as well.

And then that way you can also work out if that GP might need like a double appointment booked to be able to spend a bit more time to go through your concerns and your questions in a bit more detail. So there’s flexibility within that

Admins likely to say, oh would you need a long appointment then?

– Correct.
– And that’s the other thing because obviously there are bulk billing GPs that you can go to and if finances are something that you are tight on then you may not know if you’re going to a bulk billing GP, you may not know them when you’re going into this. So yeah, giving them the heads up is always a good idea to allow them to be as prepared as possible.

Seeking a Second Opinion and Other Medicare Plans

Okay. I’ve been to the GP, I didn’t know them. Bulk billing GP. My GP is actually super expensive and you have to pay out of pocket and I just really wanted to spend, because it’s a long appointment, it was going to cost me $120 to go to this one. So I actually went to a bulk billing one. I said no,

– Yes, – But I’m still sure I’ve got our resource. I’m, I’m just so sure that my child or that myself fits this criteria, what should I do now?

I think something we always remind our families that GPs are just one part of the process and if a GP says no, you are absolutely allowed to seek a second opinion because as we said before, some GPs are more familiar with developmental needs than others. Some may have more experience with doing these plans. So if you strongly believe that your child needs support, keep advocating and we can provide a letter to summarise your concerns to take back to the GP or you can use the notes that we provide for our discovery call or you can use past reports that you may have or teacher reports. All of those things are really going to help you to provide evidence, especially if you then go seek a second opinion.

That’s it. The word of one person does not, the path doesn’t end there.

Exactly. Then it’s like one person’s decision is not that you’re not going to gate keep that No from you, you are definitely allowed to seek… If you can get two or three no’s then maybe you don’t meet criteria, but

– Exactly.
– If you get one no, but you’re still pretty certain that you meet criteria. We’ll definitely give it another shot and maybe ask around and ask your friends who their GPs have been and if they have, have experience in the chronic condition that you are going to talk about essentially.

– Yes.
– All right.

We talked about helping children with autism funding briefly. Are there any other types of Medicare funding that parents can access?

There is the Aboriginal and Torres Strait Islander health service plans, which this is providing up to 10 allied health sessions per year at the same rebate of $61.80 each.

– Okay, so that’s double the sessions,
– Correct, yes.

And 10 sessions, I mean I think about the difference between five sessions and 10 sessions, like 10 sessions is still not adequate for achieving long-term outcomes in most areas of speech pathology. But what you can do with 10 rebated sessions as opposed to five is just fast.

– Yes.
– You know,

– And you can kind of, yeah, you, it’s double, you can kind of stagger it over, you know, fortnightly. So then that way it covers you for like 20 weeks or doing like kind of over two terms doing like fortnightly sessions or like a block of five weeks have a bit of a break and then another block of five weeks. So it can kind of be more flexible. You have a bit more autonomy with it.

Yeah. And so that is for Aboriginal and Torres Strait Islander children or adults as well?

Yes.

Yep. Fantastic. That’s really great. So I hope that everybody knows about that if they meet that criteria.

 

Key Pointers and Conclusion

Alright, so in summary, when it comes to navigating the Medicare system, what are just the key pointers or the key points that you want parents to remember?

Well I think the first one is that you don’t need a referral to see a speech pathologist, but you do need one, if you want to claim the Medicare chronic condition management plan rebate. The chronic condition management plan rebate gives up to five rebated sessions per year. Always book in with your GP first and bring reports, teacher feedback and our resource to explain and express your concerns to your GP. And remember that if your GP says no and you still have concerns, you can get a second opinion.

So Medicare is a great starting point to be able to alleviate some of that cost to get kick started with your therapy journey.

When I think about it, we really are very lucky in Australia to have schemes like this where parents can access a rebate heaps of countries where you don’t get anything

– Exactly right.
– Thank you Monique,
– Thank you so much, Heidi.
– Hope that help. Thank you for having me
– Parents to actually just navigate the system a little bit easier and to let them know what they can and can’t do. Give them permission to advocate for their child.
– Yeah, because they are their best child’s advocate and so we really want to empower parents to be able to book that appointment and access these supports.
– Yeah, and if you’ve got any questions and you really think your child needs speech therapy, you can call up and have a discovery call with one of our experienced speech pathologists and just ask those additional questions and make sure you take that summary with you to the GP.

I hope you found this episode practical and are walking away with some simple actions or knowledge to help support your family. We’d love to hear what other funding topics you’d like us to cover. You can reach me by leaving a comment on your podcast at or sending us a DM on our Instagram at Beyond Words by Pop family.

Don’t forget to head over to the show notes to get your free copy of How to Get Medicare funding, which includes the eligibility information and our GP checklist to take with you to your appointment. Plus you can follow us for even more episodes.

Before we wrap up, I would like to acknowledge the traditional custodians of land, seas, and waters throughout Australia and pay respect to elders past, present, and future.

Please also remember that if you or your child are facing challenges in the areas we discuss today, please seek an individualised speech pathology assessment or chat to your GP.

Take care and we’ll see you next time.