Referrals, private health insurance, Medicare rebates, and NDIS funding: frequently-asked questions and answers

Over the years, we’ve had lots of great questions from clients about speech pathology referrals, private health insurance, Medicare rebates and NDIS funding.

On this page, we answer our most frequently-asked questions. We also include some links so you can read some of the rules in more detail.

We’ve tried to explain things clearly. But the rules are sometimes a bit complicated.

We do our best to keep this page up-to-date. But ongoing health and NDIS reforms mean that:

some rules have recently changed; and
some rules are under review right now.

If you have any questions about any of these topics, please get in touch. We will do our best to help you.

1. Do I need a referral to see a speech pathologist?

No. In Australia, you do not need a GP or paediatrician referral to see a speech pathologist for an assessment or therapy.

2. Can I use private health insurance for speech pathology services?

If you have private health insurance with extras cover that includes speech pathology services, you may be entitled to make a claim for speech pathology service from your health fund. Check with your insurer.

We can process private health fund claims on the spot using HICAPS so you only need to pay the gap.

3. To get a Medicare rebate, do I need a medical referral?

Yes. If you think you or your child might be eligible for a Medicare rebate, you should consult with your GP.

The different rebate names and rules are all a bit confusing, and have recently changed. We summarise them below.

4. What Medicare rebates might be available for some speech pathology services?

There are three main Medicare rebates that are available for some speech pathology services:

Rebates for people with an “eligible condition” (including stuttering and speech disorders)
Rebates for people with “Chronic Health Conditions” (including some speech and language disorders)
Complex neurological condition rebates (including intellectual disability, autism, and global developmental delay)

Below, we outline each rebate. If you have any questions, please feel free to get in touch with us!

A. Medicare M10 rebates for clients under 25 with an “eligible condition”

To access this rebate, the client must be:

under 25 years of age; and
have a referral from a GP, consultant physician, or specialist; and
suspected of, or diagnosed with, an eligible condition under the so-called M10 list.

Eligible conditions for this rebate include:

stuttering
speech sound disorders, including:
- articulation disorder
- phonological disorder
- childhood apraxia of speech (also known as dyspraxia, developmental verbal dyspraxia, or speech apraxia)
- dysarthria
cleft lip and/or palate
cerebral palsy
Down syndrome
fetal alcohol spectrum disorder (FASD)
Fragile X syndrome
Some hearing impairments
Rett syndrome (previously Rett’s disorder)
Williams syndrome

The full list of eligible conditions can be found here.

Eligible clients can claim a rebate for: 

Up to 8 assessment sessions 
Up to 20 treatment sessions

Developmental Language Disorder is not an eligible condition.  Nor are learning disorders, like dyslexia or dysgraphia.

B. Chronic Health Condition Medicare rebate

Previously, this Medicare rebate was known as a Chronic Disease Management plan (CDM). Before that, it was called an Enhanced Primary Care plan (EPC). Some GPs and other health professionals still call it a “CDM” or “EPC”.

To access this rebate, you need a GP referral; and the GP must write a Chronic Health Condition Management Plan.

The rebate is available for children and adults with “chronic conditions”. Chronic conditions can include speech, language and other communication disorders.

Clients with “chronic conditions” may be eligible for a Medicare rebate for up to 5 therapy sessions per calendar year. (We can give you more information about this on request.)

You can read more about this rebate here.

C. Medicare rebate for complex neurological conditions

To access this rebate, you need a referral from a psychiatrist or paediatrician and to have a Medicare card. You also have to:

have, or be suspected by a psychiatrist or paediatrician of having a diagnosed “complex neurological condition”;
be under 25 years of age; and
not be in hospital.

“Complex neurodevelopmental conditions” may:

include conditions like intellectual disability, autism, and global developmental delay;
cause functional impairments in areas like cognition, language, social-emotional development, and social skills.

You can read more about the rebate here.

5. If eligible for a Medicare rebate, will “gap fees” be payable?

Yes. Medicare rebates do not cover the full cost of speech pathology services. Before your first session, we will explain our fees in detail so you know the gap.

6. NDIS funding

We provide speech, language, and communication assessment and therapy services to self-managed and plan-managed NDIS participants and their families.

For regulatory reasons, we do not currently work with participants whose plans are managed by the NDIA. (These plans are sometimes called “agency-managed” or “NDIA-managed” plans.)

NDIS funding rules continue to change as part of wider NDIS reforms. We regularly update clients about these changes. (You can read about some of the most recent changes here.)