The Medicare chronic disease dental scheme was introduced in November 2007. The scheme allows chronically ill people who are being managed by their GP under an Enhanced Primary Care (EPC) plan access to Medicare rebates for dental services.
Under the Medicare chronic disease dental scheme, Medicare benefits are available for most services provided by a dentist, dental specialist or dental prosthetist in private dental surgeries.
To receive a Medicare benefit for dental services, you will first need to meet certain eligibility criteria and be referred by your GP to a dentist.
Which patients are eligible for dental services under the Medicare chronic disease dental scheme?
To be eligible, you must have a chronic medical condition and complex care needs and your oral health must be impacting on, or likely to impact on, your general health.
A chronic medical condition is one that has been or is likely to be present for at least six months. It may include, but is not limited to, conditions such as asthma, cancer, cardiovascular illness, diabetes mellitus, arthritis, mental illness, musculoskeletal conditions and stroke.
Complex care needs means that you are receiving ongoing care from a multidisciplinary team, which includes their GP and at least two other health care providers.
In practice, this means the patient will need to be managed by their GP under certain care plans. For most people this involves the preparation of a GP Management Plan and Team Care Arrangements. For residents of aged care facilities, it involves the GP contributing to a multidisciplinary care plan prepared for the resident by the facility.
Patients should talk to their GP about whether they are eligible for these plans. If they are eligible their GP must complete the plans and bill them before the patient has their first dental service.
Once you have been referred by your GP to a dental practitioner, you can call Medicare Australia on 132 011 to check that the necessary GP care planning items have been claimed and paid before starting dental treatment even where your GP has signed a referral form. If the relevant items have not been claimed and recorded, Medicare Australia cannot pay benefits for dental services.
What dental services will the Medicare chronic disease dental scheme cover?
A comprehensive range of dental services will be covered, including dental assessments, preventive services, extractions, fillings, restorative work and dentures.
The primary purpose of the dental treatment must be to improve oral health or function. Medicare rebates will not be paid for dental services that are purely cosmetic in nature.
Under the Medicare chronic disease dental scheme, Medicare rebates cannot be claimed for dental treatment provided by public dental clinics or where the patient is an in-patient (i.e. an admitted patient) in a hospital.
Who can provide the services?
Most privately practising dentists, dental specialists and dental prosthetists will be eligible to provide services under the Medicare chronic disease dental items, but some may choose not to treat patients under Medicare.
How do the GP referral arrangements work?
If you meet the eligibility criteria, you will be referred by your GP to a dental practitioner for further assessment and treatment.
In most cases the patient will be referred to a dentist. If the patient has no natural teeth and only needs to have a full denture made, or a partial or full denture repaired or maintained, the GP can refer you directly to a dental prosthetist.
The referral will last for two consecutive calendar years from the first dental service. If additional treatment is required after this period a new referral from a GP is required.
The dentist can refer a patient onto a dental specialist, if required, or to another dentist or dental prosthetist. The dental prosthetist can refer a patient onto a dentist or another dental prosthetist.
To refer a patient onto another dental practitioner, the dental practitioner can write a letter or note. There is no need to get another referral from the GP.
How do patients claim for dental services under Medicare?
Patients can claim Medicare benefits for dental services in the same way as other Medicare services (e.g. by visiting a Medicare office to claim a rebate).
