Does health insurance cover occupational therapy?

Keeping busy is good for physical health, living independently is good for mental health and having valuable skills is good for financial health.

Occupational therapy does all of these across areas including rehabilitation, aged care, mental health and paediatrics. Generally speaking, if it involves helping someone live a normal life despite extenuating circumstances, it is probably occupational therapy.

Compare health insurance for occupational therapy

What occupational therapy costs will health insurance cover?

Does health insurance cover therapy? The answer to this question is sometimes. Because occupational therapy is such a broad category, certain components are covered by Medicare while others are only covered by private health funds. Some may be covered by both, and some may be covered by neither.

Private health funds

Private health funds can cover occupational therapy, but will usually require you to purchase more comprehensive extras (or ancillary) options. They will typically only cover a portion of the costs, usually 60–75%.

Before covering occupational therapy, many private health insurance brands may also require:

• Referrals from doctors
• Your occupational therapist to be licensed and registered with Medicare, or to similar standards
• Your treatment to be carried out with the goal of treating a medically diagnosable condition

Private health funds will readily subsidise occupational therapy if the conditions are fulfilled. Beware of low limits, however: your annual occupational therapy limit might be, for example, only $450 per year. This would be enough for occasional sessions, but is too low for extensive therapy following an accident or ongoing treatment for a disabled child.

Although the actual occupational therapist session limits may be relatively low, most private health funds cover medical and assisted-living devices, such as wheelchairs, separately under health aids.

Medicare

To claim occupational therapy sessions with Medicare you typically need to have been referred to the provider by a licensed healthcare practitioner, and the occupational therapist must be a registered member of the Occupational Therapy Board of Australia.

Referrals will generally be made if:

• Occupational therapy can help someone with a developmental disorder such as autism.
• The practitioner believes it can help someone who has a medically diagnosable mental illness or disability.
• It is for a child who has a specific disorder, such as Down syndrome, which can benefit from occupational therapy.
• If occupational therapy is needed to use assisted-living devices or achieve certain outcomes, like being able to return to work or live independently with a disability.

With a valid referral, Medicare will cover 100% of the cost of a limited number of treatment sessions per year, typically about five to fifteen, depending on the condition. In some cases the outcomes achieved must be reviewed after a certain number of treatments; if the occupational therapy is achieving good results then more sessions may be approved. As a very rough rule of thumb, if your disability qualifies you to receive a disability support pension then occupational therapy may be relevant to your needs.

When occupational therapy is covered by Medicare:

• You get complete cover of a certain number of sessions.
• You typically require a referral for an occupational therapist from a recognised healthcare practitioner.
• Depending on the disability or health issue being treated, there are slightly different criteria you must meet to get coverage.

How do I claim occupational therapy on my health insurance?

To claim occupational therapy through Medicare you must:

Step 1. Acquire a referral for occupational therapy services from a practitioner registered with Medicare.

Step 2. Your therapist will report progress back to the referrer.

Step 3. The therapist will claim the expenses directly from Medicare.

Step 4. Continue attending scheduled sessions until you achieve the desired result or you reach the treatment limit. If you have reached the limit then you may be eligible for further sessions, following a review of your case. This is between the therapist, the referrer and Medicare, so you should not have to get involved or make a case.

If you are lodging your occupational therapy claim through a private health fund you will have to:

Step 1. Visit an approved occupational therapist recognised by your health fund. If you are unsure whether a practitioner is approved you can simply ask them.

Step 2. Pay the portion of their fees that you owe. The remainder (to be covered by insurance) can be paid in varying ways depending on your health fund and might involve swiping an insurance card, sending in a claims form or simply letting your therapist work it out with the insurance company.

Step 3. Be mindful of limits. If you exceed your health fund’s annual or lifetime limit for occupational therapy services, even by accident, then you are still liable for outstanding costs.

What terms should I look for in an insurance policy?

Look out for some specific terms when selecting an insurance policy.

• Exclusions. These are not covered. In health insurance for occupational therapy you might encounter exclusions like:
  • Services outside Australia (approved occupational therapists are required to offer their services in Australia).
  • No cover unless there is a named purpose for the procedures. For example, you could likely get cover for occupational therapy which reteaches fine motor skills following brain injury through a sewing class, but could not for a standard sewing lesson.
  • Additional costs like administration fees are generally not covered.

• Limits. These are the maximums of your policy, or the most you can claim in a certain period of time. These maximums can be a certain number of treatment sessions or a dollar value of treatments.
  • Medicare has limits on the number of occupational therapy sessions per year.
  • Private health funds typically have value limits on occupational therapy treatment per year, such as $450 worth of sessions a year.

• Excess. This is an additional fee to be paid upon making a claim. Because occupational therapy will typically involve multiple claims, you should be very aware of your excess.
  • Older age groups have higher excesses.
  • If the claimable event required going to hospital then there may be an excess for this.
  • Pre-existing conditions, a history of making health insurance claims or ongoing health issues may incur a special excess.

If you are unsure of how these may interact with your occupational therapy health insurance claims, contact your insurer for answers. Generally, however, it is important to be aware of these factors as they greatly affect the actual level of cover offered. Largely, because of the applicable limits and excesses, private health funds are not necessarily the best option for people who require extensive or ongoing occupational therapy. They are better suited to people who may require a few sessions at some point in their life.

What sort of services does occupational therapy offer?

• Teaching people how to live with ongoing injuries or illnesses.
• Assessments of whether a disabled person can drive safely, or can carry out certain tasks.
• Teaching developmentally delayed children the everyday skills they will need in life.
• Training people in the use of wheelchairs and other assisted-living devices.
• Arranging employment for disabled people and following up to see if it’s suitable.
• Assessing the need for assisted-living devices for elderly or disabled individuals.
• Helping people with mental illnesses care for themselves and others.

Who can benefit from cover for occupational therapy?

Everyone is able to benefit from the occupational therapy offered by private health funds, but usually only in a few circumstances. For the people who really need it, Medicare does a better job of making occupational therapy affordable. There may also be other funds earmarked for occupational therapy, such as workers compensation or total and permanent disability (TPD) insurance.

• Medicare. Generally a better option for people looking to treat specific conditions or achieve certain outcomes through occupational therapy, as long as these conditions and outcomes are approved. The Medicare limits may still be too low to achieve all the results you want, but it will greatly defray the cost.

• Private health insurance. Generally more for people looking to cover incidental occupational therapy needs, such as wheelchair training following an accident or group therapy to learn how to live with disabilities. For treating specific issues, the cost of health fund premiums and the low limits mean it is not generally value for money.

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