Will Private Health Funds Cover Occupational Therapy?
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If you’re living with the aftermath of an accident, injury, illness, health condition or other situation that has rendered you unable to live independently, occupational therapy is likely to be beneficial for you. Occupational therapists are specially trained to help people in this situation overcome their limitations. They accomplish this using multiple approaches:

  • Overseeing the modification of each patient’s environment as necessary to make it more accessible
  • Recommending adaptive equipment – for example, splints or wheelchairs — that may be helpful for encouraging the patient to conquer physical limitations
  • Designing a treatment plan that incorporates mental health treatment plus various exercises, possibly including mobility exercises and / or mental exercises
  • Planning recreational and educational activities that help to improve the patient’s condition
  • Coordinating treatment with the patient’s GP and other healthcare providers to ensure continuity of care

What Are Your Options for Care If You Need Occupational Therapy?

Medicare

Occupational therapy is generally considered to be one of the allied health services. There are some circumstances in which Medicare might cover up to 5 allied health visits per year, or up to 4 visits per year for a child under the age of 13 years.

In order for Medicare to cover these costs, the adult patient must have been properly diagnosed with a chronic condition such as diabetes, cancer or stroke. A child must typically have a pervasive developmental disorder or similar disability or condition to be eligible for Medicare to provide funding. The patient’s GP must initiate the occupational therapy visits by incorporating occupational therapy treatments into the patient’s overall care plan. The GP must also provide a referral to an occupational therapist for the visits, and must obtain a progress report from the occupational therapist after each treatment session.

If these conditions are not met, it is unlikely that Medicare would cover the costs associated with your consults. Realistically speaking, Medicare does not cover most types or instances of occupational therapy.

Private Health Insurance

Private health insurance sometimes covers occupational therapy, and sometimes it does not. The extent of coverage depends on the specifics of the policy you choose to enrol in.

Some private health funds cover occupational therapy services under their extras cover policies  (also known as ancillary cover). You must read the terms and conditions of each policy carefully to understand which services are included, which are excluded, and what limits apply.

Your insurer is likely to place annual limits and lifetime limits on the occupational therapy services they will cover. You could expect to encounter either limits on the number of therapy sessions or limits on the dollar value of treatments to be covered — or, sometimes, both.

Exclusions are another possibility to be aware of when you use private health insurance to cover occupational therapy costs. For example, you’re likely to find exclusions on care rendered outside of Australia. You’re also likely to find that administrative fees are not covered.

It’s also important to be aware of the amount of excess you’ll be subjected to when making a claim.

Some policies are better than others. If you’d like to enrol in a private health fund that will cover occupational therapy, it’s beneficial to compare health insurance plans using our dedicated search engine. This could help you to identify policies that offer the most generous benefits for occupational therapy. You might also wish to perform a comparison if you’re already enrolled in an extras cover policy but wondering if you’re getting the maximum possible value for the money you’re spending on premiums.

Private health insurance tends to be a viable option for people who need occupational therapy on a short-term basis. It can be an excellent value in cases where you need help immediately following an accident.

If it seems likely that you will need ongoing, long-term occupational therapy, it is less clear whether or not private health insurance would offer a realistic value for the money spent. All the possible variables, including low limits on claims, the cost of the excesses, the upfront cost of the premiums, and the exclusions, must be considered when making an evaluation.

No Double Dipping on Claims

In situations where your care could be covered by either Medicare or a private health fund, you’ll have to choose one or the other to pay your claims. If you claim for your occupational therapy through Medicare, you cannot also legally use your private health extras cover to “top up” your Medicare rebate for the same sessions.

Pay Out of Pocket

As noted above, there are limitations on the number of occupational therapy visits that Medicare will cover. Private health funds also typically place limits on occupational therapy services. There are likely to be situations in which patients requiring occupational therapy would have to pay out of pocket for their care.

So now you’re updated on whether private health insurance covers occupational therapy, and also about the most common options for funding occupational therapy treatments. We hope this information is helpful to you as you consider your options for care.

We invite you to call us on 1300 806 119 if you have questions or would like assistance with choosing a suitable health insurance policy. It can be a bit overwhelming to sort out all the details, but we’ve invested heaps of time in figuring out all the nuances of what makes each policy unique. We’d be delighted to help.

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