Yes, Medicare covers physiotherapy, but it’s specifically for patients with chronic medical conditions requiring complex, ongoing care. That means you can’t receive Medicare-rebated physiotherapy just because you hurt your knee; it needs to be an ongoing problem (see eligibility requirements below for more information). Under Medicare’s Chronic Disease Management (CDM) program, eligible patients may access physiotherapy under MBS Item 10960. This program supports patients who need coordinated care involving multiple healthcare providers.

Number of Physiotherapy Visits Covered by Medicare

Medicare allows up to 5 physiotherapy services per calendar year for eligible patients. These 5 services can be used exclusively for physiotherapy or can be split between other eligible allied health services (e.g., dietetics, podiatry) if required.

Cost of Physiotherapy Sessions and Medicare Rebates

Each physiotherapy session covered by Medicare must be at least 20 minutes in duration. The standard fee for a physiotherapy session under Item 10960 is $70.95, and Medicare covers 85% of this fee, equating to $60.35 per session. Here’s how the costs and rebates work:

  • Cost per Session: $70.95 (set by Medicare)
  • Medicare Rebate: 85% = $60.35
  • Out-of-Pocket Expense: Many clinics (including Benchmark clinics) charge a small fee on top of the medicare fee to cover the costs of delivering high quality physiotherapy.

Additionally, patients may benefit from the Extended Medicare Safety Net if they have high medical costs throughout the year. This safety net may cover additional out-of-pocket expenses for services that meet the Medicare requirements, up to a cap of $212.85 per year.

Eligibility Requirements for Medicare-Funded Physiotherapy

To be eligible for Medicare-covered physiotherapy under Item 10960, several conditions must be met:

  • Chronic Condition: The patient must have a chronic medical condition, which is defined as one that has lasted, or is expected to last, at least six months. Conditions commonly considered chronic include diabetes, arthritis, heart disease, and chronic musculoskeletal issues.
  • Complex Care Needs: The patient should have complex care needs that require coordination between multiple healthcare providers, which may include a GP, physiotherapist, and other allied health professionals.
  • Managed Care Plan: The patient must be managed by a GP under:
    • A GP Management Plan (GPMP), which outlines the patient’s healthcare needs and treatment goals, and
    • Team Care Arrangements (TCA), which involve a coordinated approach from the GP and at least two other health professionals (e.g., physiotherapists, dietitians).

Steps to Get a Referral for Physiotherapy

A GP referral is essential for accessing Medicare rebates for physiotherapy under the CDM program. Here’s how to obtain it:

  1. GP Assessment: Start by scheduling an appointment with your GP. During this visit, the GP will assess your condition to determine if it qualifies as chronic and whether your care requires support from multiple healthcare providers.
  2. Creation of Care Plans: If you qualify, the GP will create a GP Management Plan (GPMP) and Team Care Arrangements (TCA). These documents detail the care required for your condition and outline the roles of various healthcare providers, including the physiotherapist.
  3. Issuance of Referral: With the care plans in place, the GP will issue a formal referral to a physiotherapist for the number of sessions deemed necessary. The referral will specify the services under Item 10960, and it must be filled out on a Medicare-compliant form, either issued by the Department of Health or containing the same information.
  1. Documentation and Reporting: After each session, or at least after the first and last sessions if multiple services are provided, the physiotherapist is required to send a written report to your GP. This report helps your GP stay informed about your progress and any further treatment needs.

Additional Considerations

  • Unused Services: If a patient doesn’t use all five services by the end of the calendar year, any remaining sessions will not carry over. The patient will need a new referral and updated care plan from their GP to access additional services in the new year.
  • Re-assessment: For continuing care, your GP may conduct periodic reviews of the GPMP and TCA to ensure they remain relevant to your condition.

Contact Us for Physiotherapy in Sydney

If you’re in Sydney and need physiotherapy, contact Benchmark Physio today. Our team can help you understand Medicare’s coverage options and guide you through the referral process, ensuring you receive the best possible care. We’ve worked alongside countless GPs over the years and have a close relationship with several GP clinics across Sydney. So talk to your GP today and see if they recommend Benchmark Physio.