Medicare covers occupational therapy for children and adults in Australia, but you'll need a referral and it only covers 5 sessions — the current rebate is $55.10. Fortunately, a handful of comprehensive extras insurance policies can cover you if you need more.
Here's a list of the insurers that will cover you for occupational therapy. All prices are based on a single individual with less than $90,000 income and living in Sydney.
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Occupational therapy includes a range of services, including as follows:
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:
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 may 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.
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:
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.
Most types of occupational therapy are not covered by Medicare. Generally, only specific therapies for specific disorders or disabilities will be covered and you have very little control over the treatment offered.
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.
If you are lodging your occupational therapy claim through a private health fund, you'll 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.
Look out for some specific terms when selecting an insurance policy.
Generally, 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 and are hoping to meet a wide range of these costs through insurance. That said, it could still be worth doing a full comparison of your options with health insurance.
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