Medicare changes to Autism Diagnosis

There was an important change to Medicare on the 1^st March 2023 that you need to know about, and share with your networks.  A Medicare rebate is now available for diagnostic assessment of complex neurodevelopmental disorders and eligible disabilities prior to 25th Birthday (0-25yrs).

IMPORTANT NOTE:  We are seeking clarification from Medicare on the changes and how they will be applied.  Some of the information in the explanation notes is contradictory.  We will update the information as soon as we hear from Medicare.

As of the 1^st March 2023, it is our understanding that GPs can now write a referral to private diagnosticians for a range of eligible disabilities, with a Medicare rebate applicable.  We are seeking clarification from Medicare on whether autism diagnostic assessment will require referral by paediatrician or psychiatrist, or whether a GP can make the referral.

Previously diagnostic reports from a paediatrician, psychologist and speech pathologist were required for an autism diagnosis to be formalised in WA for kids aged 0-12yrs. For NDIS access for children aged 0-12yrs, an autism diagnostic assessment would need to be performed by any two of the three diagnosticians listed above.  Most schools will also now allocate Education Assistant funding with a diagnosis from only 2 of the 3, bringing WA into line with the rest of Australia (as per the National Guidelines for Autism Diagnosis).

For kids aged 13-17yrs, diagnosis will need to be by registered or clinical psychologist, and will often need a paediatrician or paediatric psychiatrist to confirm the diagnosis.  Sometimes diagnosis by clinical psychologist alone will be sufficient.

The Medicare rebate is now available for people aged 0-25yrs, and as stated above, GPs are able to provide the referral for eligible disabilities in the list below.  You can find out more about the changes at:

• Medicare
• Services Australia

Diagnostic assessments for the following eligible disabilities are covered by the change:

• sight loss resulting in vision of less than or equal to 6/18 vision or equivalent field loss in the better eye, with correction
• hearing loss with either
  • a hearing loss of 40 decibels or greater in the better ear, across 4 frequencies
  • permanent conductive hearing loss and auditory neuropathy
• deafblindness
• cerebral palsy
• Down syndrome
• Fragile X syndrome
• Prader-Willi syndrome
• Williams syndrome
• Angelman syndrome
• Kabuki syndrome
• Smith-Magenis syndrome
• CHARGE syndrome
• Cri du Chat syndrome
• Cornelia de Lange syndrome
• Microcephaly, if a child has
  • a head circumference less than the third percentile for age and sex
  • a functional level at or below 2 standard deviations below the mean for age on a standard development test or an IQ score of less than 70 on a standardised test of intelligence
• Rett’s disorder
• Foetal Alcohol Spectrum Disorder (FASD)
• Lesch-Nyhan Syndrome
• 22q deletion syndrome.

Please note that for people needing to access the public diagnostic pathway through Department of Communities – Disability Services for Autism or Intellectual Disability, a paediatrician referral is still required.

This is a very significant and important change for desperate families trying to access diagnosis and support for their children.  There are currently huge waitlists for paediatricians in WA, with many having closed their waitlists completely.  SWAN are working to share information about this important change widely, in the hope that this will alleviate paediatrician waitlists and enable families seeking diagnostic assessment for complex neurodevelopmental disorders and disability will no longer be forced to wait 2-4 years to access diagnosis and support services.

Please contact us if you would like more information about this change, and what it means for you / your family member.