Changes to Pilates Claiming with Private Health Insurance

What’s changing to Pilates claiming?

The Department of Health has made changes to legislation which applies to private health insurance. The purpose of these changes is to remove private health insurance funding for therapies which are not medically based.

There are certain types of natural therapies, including “Pilates”, which will no longer be eligible for private health insurance rebates from 1^st April 2019. This has caused a lot of confusion about who these changes will affect and why.

There are different types of Pilates classes in Australia, including many which are not run by Physiotherapists, run for fitness-purposes only (not for clinical reasons), are not helping to manage any current medical issues or injuries, and are not run by adequately qualified instructors. These types of Pilates classes will no longer be claimable with private health insurers.

Does it affect my classes at Move?

As Physiotherapists are qualified allied health professionals, who can diagnose issues and prescribe interventions including treatments or exercises, you should still be able to claim for the classes which are under the Physiotherapy Group and Class consultation item code. However, as each private health insurer is its own private company, they can enforce their own rules if they choose.

At Move, our Equipment and Gym classes fall under the Group Consultations item code.

These Group Consultations are:

• Based on a thorough initial assessment with a Physiotherapist
• Have an evidence based and therapeutic framework
• Run by Physiotherapists

We also:

• Record clinical notes for each class you attend, to track your progress and any issues you’re experiencing
• Perform regular reviews of your exercises to keep them up to date and relevant for you
• Use correct language on our invoices. This language is in line with the changes to private health claiming, and accurately reflects the item code you are claiming

Because we do these things, these exercise services should continue to qualify for private health rebates with the majority of private health insurers, (providing you have Physiotherapy extras cover).

The classes that do not fall under a Group or Class Consultations code and are not claimable on private health insurance, include our Pilates Mat and Pilates Reformer classes. This is because the classes not tailored to each participant, and are geared more towards fitness, maintenance, and general strengthening.

What do I need to know?

Many private health insurers require you to have an assessment every year if you are currently partaking in Group or Class Consultations with a Physiotherapist. (Although as we mentioned before, each fund has its own rules, so to be certain if this applies to you, we recommend you check with your insurer directly).

If you are a attending a class which falls under the Group or Class Consultations code and have not had a review within the last 12 months, then we strongly advise you contact us to book one in.

We have always recommended regular reviews, especially if your condition has changed. Reviews are important in ensuring your exercise program is still appropriate, challenging, and relevant. It also means that we can adapt your exercises to suit any new goals or issues which may have developed since your program was originally written.

What do I do if I can’t claim Physiotherapy Group or Class Consultations under my private health insurance?

Each fund is its own company with its own rules. If your health fund doesn’t cover Physiotherapy Group or Class Consultations, feel free to speak to us and we may be able to assist you to find one that does.

Remember – you don’t need to have your Extras and Hospital cover with the same Private Health Insurer, you can get your Extras through one insurer and Hospital with another if you find that works better for you.

Is anything else affected by these Private Health Insurance reforms?

Yes – these changes to Pilates claiming stem from the Private Health Insurance Reforms in 2017. There were a number of other changes recommended in these reforms, which will come into effect from 1^st April 2019, including:

• There will be a new system of categorising health insurance products. From 2019, there will be four categories of hospital products (Gold, Silver, Bronze and Basic) and three categories of extras (Gold, Silver and Bronze). There will be funding allocated to the development and introduction of these categories, as well as an expert committee put in place, to ultimately make health insurance easier to understand.
• Easier access to mental health services. Those with limited mental health cover will be able to upgrade their insurance (without being stuck with a waiting period) to access in-hospital mental health services. This creates easier access to these services, and helps prevent out of pocket costs to patients.
• A committee will be created on Addressing Low Value Care, and will give the government advice on further changes to prevent low value insurance or inefficient care. It will support future reforms to the industry, and will be developed over the coming years. There will also be a committee to help the government determine how to make out-of-pocket costs easier to understand.
• Standardization of clinical definitions used in documentation used by private health insurers. Many Australians are happy to hear the Clinical Definitions Working Group has developed a list of standard definitions (that are meant to be “consumer-friendly” terms) to help consumers compare and understand different policies.
• The Private Health Insurance Ombudsman can conduct audits on private health insurers, to ensure they are meeting these regulations. A number of operational changes within the Ombudsman also means they have a better website (privatehealth.gov.au), more staff, more access and more power to address consumer complaints.
• Discounted private health insurance policies are able to be offered to people aged 18 – 29. While current legislation prevents companies from offering discounts based on age, this will soon change to allow young people discounts on hospital premiums for up to 2% for each year they are under 30 (capped at a 10% discount). This will be phased out after 40 years of age.
• Consumers can choose higher excesses to lower their premiums. Previously, the maximum excess you could choose for your private hospital insurance was $500 for singles and $1000 for couples/families. From April 2019, this will change to $750 and $1500 respectively, and should contribute to reducing price increases.

Hopefully this gives you some more insight into these changes. If you’d like to read the full list of the private health insurance reforms, which includes further information on administrative changes, options for privately insured patients in public hospital, and changes to support private hospitals, you can visit the Department of Health website.

Alternatively you can visit the Australian Physiotherapy Association, which provides information on all the above, on their website here.

Move for Better Health