Medicare Chronic Disease Dental scheme

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.

At ArtarmonFineDental, we accept clients  that are under the EPC , but DO NOT bulk bill medicare, so essentially there is an out of pocket GAP expense payment .We can prepare a thorough treatment plan for you (after a comprehensive examination consultation) that will outline the exact costs of treatment fees with each options available. You can then work out your out of pocket GAP payment  by going to Medicare to check what their rebate is prior to starting treatment .    

The full treatment fees are paid as normal up front on the day of treatment completion and a receipt is issued which you can then use at Medicare to claim back your rebate under the EPC sheme.

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 their GP to a Dentist like ArtarmonFineDental. 

Who is 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 their oral health must be impacting on, or likely to impact on, their 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 your patient is receiving ongoing care from a multidisciplinary team, which includes their GP and at least two other health care providers.

In practice, this means you 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.

If you beleive you fulfil the criterias, You should talk to their GP about whether you are eligible for these plans. If you are eligible your GP must complete the plans and bill them before you have your first dental service.

Once you have been referred by their GP to a dental practitioner, the patient 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 their 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.Eligible patients may access Medicare benefits of up to $4250 in total over two consecutive calendar years  for dental services.

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 a GP to us for further assessment and treatment, including full or partial dentures.

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.

What will a patient have to pay for the dental services?

Dental practitioners are free to set their own fees for services. To ensure you are aware of the potential costs you will need to obtain a written quote before starting a course of treatment, which we are happy to provide with full costings, and itemisation.

As ArtarmonFineDental, DO NOT bulk bill you the patient, there is an out of pocket gap payments for you to pay up front on the day of treatment .A receipt will be issued which you can used to get the rebate back from Medicare. 

For more information

For more information about the Medicare dental services, go to the EPC Chronic Disease Dental Scheme website or call the Medicare Australia Provider Enquiry Line on 132 150.