Occupational therapy and health insurance

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.

Compare health insurance for occupational therapy

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 $97,000 income and living in Sydney.

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Using private healthcare for occupational therapy: Pros and cons

Pros

• Many types of occupational therapy aren't covered by Medicare. Your private health fund may offer you access to a wider range of options and treatments.
• If you've used up your available sessions through Medicare, your insurance can help with future expenses for more services.
• With wide-ranging health insurance in place, you could supplement your occupational therapy benefits with related perks listed under 'health aids'. For example, cover for assisted-living devices such as wheelchairs.

Cons

• Benefit limits tend to be capped at around $500. This may be okay for occasional sessions, but it'll fall short of more extensive therapy plans. If you're recovering from a traumatic injury, or you need ongoing treatment for a disabled child, you wouldn't be able to rely on this particular insurance cover.
• Even with a top-draw extras policy, you may only cover between 60% and 75% of the full cost of a private session. Coupled with the aforementioned benefit limits, you may struggle to see a clear advantage with private cover, when you factor in the price of your premium each month.

What type of services does occupational therapy offer?

Occupational therapy includes a range of services, including as follows:

• 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.

Which occupational therapy costs are covered by health insurance?

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 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.

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.

How do I claim occupational therapy on my health insurance?

Medicare

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.

Private health insurance

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.

What terms should I look for in an insurance policy, when it comes to occupational therapy?

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.

• Benefit limits. These are the maximums of your policy, or the most you can claim in a certain period of time. These benefits 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 benefit limits on occupational therapy treatment per year, such as $450 worth of sessions a year.

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.

Frequently asked questions

• What is occupational therapy?

  Occupational therapy is a type of healthcare that helps to treat physical, mental, developmental and cognitive issues. It helps people whose health or disability makes it hard for them to perform day-to-day tasks.

• Can I claim occupational therapy on Medicare?

  Yes, but only up to 5 sessions per calendar year. Generally, you'll need to have a chronic medical condition that's been present for a minimum of 6 months. Your eligibility is decided by your doctor.

• 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 perhaps does a better job of making occupational therapy affordable.

  • Medicare. Generally, a favourable 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 reduce your costs.

  • 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 could mean it's not generally value for money.