Existing MBS dental items (10975-10977)

New MBS dental items (85011-87777)

Patient eligibility

Patients with a chronic condition and complex care needs whose dental condition is exacerbating their chronic medical condition, on referral from their GP under an EPC plan. That is, a patient must have in place:

• a GP Management Plan (GPMP) – item 721 (or a GPMP review item 725) AND
• a Team Care Arrangements (TCA) – item 723 (or a TCA review item 727)

OR

• for a resident of a residential aged care facility, the GP must have contributed to, or reviewed, a care plan prepared by an aged care facility (item 731).

Patients with a chronic condition and complex care needs whose oral health is impacting on, or is likely to impact on, their general health, on referral from their GP under an EPC plan. That is, a patient must have in place:

• a GP Management Plan (GPMP) – item 721 (or a GPMP review item 725) AND
• a Team Care Arrangements (TCA) – item 723 (or a TCA review item 727)

OR

• for a resident of a residential aged care facility, the GP must have contributed to, or reviewed, a care plan prepared by an aged care facility (item 731)

Eligible providers

Dentists and dental specialists

Dentists, dental specialists and dental prosthetists

Referral process

GP must refer the patient to a dentist.

Patients cannot be referred directly to a dental specialist (referred on by the dentist).

GP must use an EPC Program Referral Form for Dental Care under Medicare or a form that substantially complies with the form issued by the Department.

Patients need a new referral form when they have had all 3 services available each calendar year (referrals may cross calendar years).

In most cases, GP must refer the patient to a dentist.  However, where the patient has no natural teeth and requires dental prosthetic services only (eg full dentures), or requires repairs or maintenance to an existing denture/s the GP may refer the patient to either a dentist or dental prosthetist. 

Patients cannot be referred directly to a dental specialist (referred on by the dentist).

GP must use the referral form provided by the Department of Health and Ageing or a form that substantially complies with the form issued by the Department.

Medicare rebate

Currently $77.95 per service (to be indexed on 1 November 2007). 

Out-of-pocket costs for eligible services count towards Medicare Safety Nets.

There is no single rebate.  The rebate will vary from item to item.  Rebates for individual items to be set out in a new MBS dental schedule.

Out-of-pocket costs for eligible services count towards Medicare Safety Nets up to the limit of $4,250 over two consecutive calendar years.

Limits on services

3 services per patient, per calendar year.

Total annual benefits = $233.85 + Safety Net benefits (where applicable).

Patients must have a dental assessment by a dentist (item 10975) as their first service, then a dental assessment every year they are referred by a GP.

Up to a maximum of $4,250 in dental benefits (including Medicare Safety Net benefits where applicable) per patient every two consecutive calendar years.

No limit on total number of services.  However, some limits on specific services will apply as per DVA arrangements (eg limit of 1 oral hygiene instruction service per 12 months).

No mandatory requirement that a patient has a dental assessment. Access to services based on clinical needs.

Dental Prostheses
(eg dentures)

The cost of supplying dental prostheses is not covered by Medicare.  However, the cost of fitting prostheses can be included under 10976 or 10977.

The cost of supplying and fitting dental prostheses can be included under the relevant new dental items.