Enhanced Primary Care

Information For Patients – Dental Services Under Medicare For People With Chronic And Complex Conditions

Overview

Some patients may be able to receive dental services under Medicare. Medicare benefits will be 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. In some cases, your GP will be able to refer you directly to a dental prosthetist for denture work.

Which patients are eligible for dental services under Medicare?

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, In practice, this means that you will need to be managed by your 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.

You should talk to your GP about whether you are eligible for these plans. If you are eligible, your GP must complete the plans and bill you prior to you having your first dental service. You may already have care plans in place. If so, you should talk to your GP about whether you are eligible for referral for dental services under these plans.

Once you have been referred by your GP to a dental practitioner, you should call Medicare Australia on 132 011 to check that the necessary GP care planning items have been claimed and paid before commencing 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 Medicare 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. If you meet the eligibility criteria, your GP can refer you to a dental practitioner for further assessment and treatment.

For further information about the Medicare dental services, go to the Department of Health and Ageing website at www.health.gov.au/epc or call the Medicare Australia Patient Enquiry Line on 132 011.