Appendix 3 - Care Plans and the MBS - Terms of Recommendation(s)

The Committee recommends that:

1. Medicare must remain at the centre of Australians’ access to out-of-hospital medical care.
2. A care plan arrangement between a patient, his or her medical practitioner and his or her health fund must complement access to Medicare, not substitute for it.
3. A care plan arrangement can be constructed around services subsidised by Medicare and the Pharmaceutical Benefits Scheme.
4. No care plan arrangement should prohibit the patient from accessing Medicare-funded services, or include gap insurance for Medicare-funded services.
5. An out-of-hospital medical service related to a care plan arrangement can be covered by Medicare or private health insurance, but not both.
6. No individual medical service can be claimed by a provider on both MBS and PHI cover.
7. If a service can be performed under a care management plan or Medicare item, the patient has the right of choice on covering the cost either through Medicare or their health fund.
8. Subject to those constraints, private health funds may coordinate and pay for care plan arrangements that may incidentally involve medical and allied health services (eg checking blood pressure, air flow tests, routine physical examinations) that can also be provided under a Medicare consultation item.
9. No service funded under a care plan arrangement should also attract a Medicare benefit.  Similarly, nothing should preclude the payment by a health fund for a care plan arrangement including medical services not covered by Medicare (eg a long check-up consultation by a GP for a person with given risk factors).
10. Care plan arrangements generally should be agreed by a supervising clinician (in consultation with the patient’s usual general practitioner as clinically necessary or as requested by the patient) and the participant, and should lead to improved health outcomes for the participant.
11. The health fund should ensure that the patient’s usual general practitioner and specialists are advised that the patient is participating in a care plan arrangement.
12. While a health fund may contract health professionals to participate in the provision of care plan arrangements, those health professionals must have the clinical freedom to recommend what is best for the participant’s health outcomes.
13. In considering or participating in a care plan arrangement, nothing should prevent a patient from consulting his or her treating general practitioner or specialists about his or her treatment choices.
14. No patient should be penalised by a health fund for declining the offer of a care plan arrangement.

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