WILL HEALTH INSURANCE COVER MY CHRONIC PAIN TREATMENTS?

WILL HEALTH INSURANCE COVER MY CHRONIC PAIN MANAGEMENT? FUNDING TREATMENTS FOR CHRONIC PAIN

The financial aspects of engaging in good quality care and support services for those suffering chronic pain can be daunting, especially for a patient or their family who may already be experiencing financial strain as a result of the injury or the pain itself interrupting the ability to work and earn an income. While there are many different treatment options available, with costs varying greatly, there are a number of incentives and helpful treatment plans that can ease the financial burden on patients and their families.

WHAT ABOUT MY PRIVATE HEALTH INSURANCE?

Private health funds will typically only pay benefits from hospital cover for inpatient services, and not for things such as outpatient reviews with a pain specialist or allied health staff. Prior to any hospital admission, it is important to ensure you have touched base with your health fund to check if you will have any out of pocket costs. At Victoria Pain Specialists, prior to being admitted for any procedure with one of our specialists, we provide you with a copy of the estimated fees and item numbers (this is called Informed Financial Consent). You can then contact your health fund with these specific details to obtain a clear picture of your out of pocket costs after claiming any benefits that may apply.

Generally, if you hold private health insurance, which has no restrictions or exclusions, you are at a higher likelihood of being able to claim a benefit for the range of pain management services offered by our clinic. Some mid-tier cover options will also pay benefits, but it is important to always speak to your health fund prior to a procedure to make sure you are aware of what your out of pocket fees will be.

PRIVATE HEALTH INSURANCE EXTRAS

For outpatient care such as seeing a physiotherapist, if you have private health insurance with extras cover, you may be able to claim a benefit for allied health services through your extras. While each fund is different in terms of benefit amounts and limits (e.g. number of sessions that can be claimed per year), the claiming process is usually very straightforward. Whilst you can’t claim from Medicare and your health insurance for the same allied health services at the same time (for example, you cannot claim a psychology appointment under a Better Access plan and then claim the ‘difference’ from your health insurance), many patients may utilise one method of claiming and then the other to enable them to access care over a prolonged period of time. Waiting periods & financial status

All private health insurance agencies apply waiting periods to their covers, though these may be waived from time to time (for example as part of a promotional offer or when transferring from another fund where you have already served your waiting periods). Prior to going ahead with any inpatient procedure or outpatient allied health services, if you have taken our your insurance within the last 12 months, it is a good idea to check in with your Fund to enquire if you have served the waiting period relating to the service you want to undertake.

For patients still serving a waiting period, this definitely doesn’t have to mean all services are on hold completely. When we have a patient in the midst of a waiting period, we may work with them to schedule in-hospital treatment to commence once their cover is activated, and look at less invasive or non-invasive options (such as Allied Health) to tide them over in the interim. What about out of pocket costs

While private health insurance may be benefits towards your pain management treatment, there may still be out of pocket costs remaining after you have submitted your claim. However, it is important to remember that the services received at a specialised clinic will be of a very high quality and utilising innovative, progressive and proven therapies and treatment option endeavouring to provide you in the highest quality of service and care. An investment in good quality healthcare and support services is an investment in your recovery and optimising your pain management.

HOW CAN MY GP HELP?

General Practitioners are able to assess patients who require the support and care of allied health practitioners such as psychologists, physiotherapists, occupational therapists and dieticians for a number of different incentive programs through the Australian Government and Medicare, which have been put in place to make affordable health care available by enabling patients to claim Medicare rebates for a designated number of sessions with an allied health provider.

Two examples are a Mental Health Care Plan, for use with psychologists, and Chronic Disease Management Plan (CDMP), for use with other allied health experts such as physiotherapists.

While your GP does ultimately need to assess you and use the appropriate criteria to ensure you qualify for a treatment plan under the Medicare guidelines, most GP’s are very supportive of these plans for patients experiencing the physical and psychological effects of chronic pain.

CHRONIC DISEASE MANAGEMENT PLAN

The Chronic Disease Management Plan is a Department of Health initiative, which assists by enabling patients to gain access to allied health services and receive a rebate through Medicare. This is an especially beneficial option for patients who don’t have private health insurance with extras.

While further information is available via the Department of Health, as outlined on their website:

A Medicare rebate is available for a maximum of five services per patient each calendar year. Additional services are not possible in any circumstances.

If a provider accepts the Medicare benefit as full payment for the service, there will be no out-of-pocket cost. If not, the patient will have to pay the difference between the fee charged and the Medicare rebate.

This initiative can be used to access specialised pain management physiotherapists, occupational therapists and other allied health service providers in specialist centres across Australia. Please check with your individual service provider that they accept CDMP’s at their practice, and to confirm if there will be a gap payment or an out of pocket cost after processing your Medicare rebate. Victoria Pain Specialists is pleased to confirm that all of our allied health providers are able to see patients using a CDMP, however there will be an out of pocket gap applicable after claiming from Medicare.

See Department of HealthChronic Disease Management - Individual Allied Health Services under Medicare - Provider Information for more information.

MENTAL HEALTH CARE PLAN / BETTER ACCESS TO MENTAL HEALTH CARE INITIATIVE

Similarly as with the Chronic Disease Management Plan initiative, the Department of Health also has implemented a Mental Health Care Plan, (also known as the Better Access Initiative) program to make psychology support services more accessible to patients, enabling them to claim a Medicare rebate for psychology counselling and assessment with registered psychologists. Your GP can provide a referral for up to six sessions with a psychologist. After your initial course of treatment, your psychologist can then liaise with your GP and if appropriate, you can obtain (at the doctor’s discretion) a further referral which entitles you to a total of ten sessions for the calendar year. The sessions can be either group therapy, or for individual therapy and counselling, which offers wonderful flexibility to patients in finding the right care for their individual needs.

Further information regarding the Better Health Initiative is available [here](http://www.health.gov.au/internet/main/publishing.nsf/content/mental-ba-fact-pat “Department of HealthBetter access to mental health care: fact sheet for patients”)

Psychology is an integral element of pain management, and the input can range from meditation and relaxation, to counselling, coping strategies, and a good pain Psychologist will always work with you to identify your specific needs, and the best type of treatment for you. At Victoria Pain Specialists, we understand that not all treatment methods work for all patients, and our expert psychologists are skilled at assessing patients to ensure that they receive the best possible care by providing them with psychology and counselling services that are targeted to their needs and goals, to empower them and support them in addressing their pain issues with a team approach.

MEDICARE SAFETY NET BENEFITS

If you see a doctor often, or have tests regularly, your medical costs could be high. Visiting a doctor or having tests may cost you less once you reach a Medicare Safety Net threshold.

Once you reach the relevant threshold, the Medicare Safety Net may provide a higher Medicare benefit for all eligible services for the rest of the calendar year. This may mean that visits to your doctor or having tests could cost you less. For example, once you reach the relevant threshold, you still pay the same amount upfront to your doctor, however you may receive a higher Medicare benefit, making your out of pocket expenses much less.

Click here for more information on the Medicare Safety Net.