How the CL&P Scheme works
Prior to 2015, all patients had to formally register with the Scheme through Medicare and were issued a CL&P card, but this is no longer the case. Now patients can submit a claim to Medicare for some orthodontic work under the CL&P Scheme using an invoice from their treating orthodontist, if:
- the patient meets the eligibility criteria (see below)
- the treating practitioner is an AHPRA registered specialist orthodontist
You will need to supply your CL&P patients with an invoice using your existing Specialist Provider Number and the relevant Medicare Item numbers pertaining to the CL&P scheme (Category 7) and Orthodontics (Group C1). These item numbers, along with details on what else your invoice must include can be found in the Medicare Benefits Schedule (see below for more on this).
Please note that the following needs to be stated clearly on the account.
- Date of service
- Item number from Medicare schedule
- the words: "this is a certified patient"
Last updated 16 November 2023
From 1 November 2023, the age limit has been removed on eligibility for Medicare benefits for treatment of cleft and craniofacial conditions. This means that people of any age who have these conditions can access Medicare-funded treatment, such as orthodontic services.
This change was made by an amendment to the Health Insurance Act 1973. More information can be found here
General information on the CL&P scheme is available on the Government Services website:
Detailed criteria for patient eligibility are in the Medicare Benefits Schedule Book under Category 7.
Medicare Benefits Schedule
You can access information on the Medicare Benefits Schedule via their online site at mbsonline.gov.au. The site is not that user friendly, so:
- To access the actual MBS Book, go to the Downloads page and then scroll down and click on The January 2020 Medicare Benefits Schedule. Scroll down on this page under Publications to download just the relevant Category 7 section in word or pdf.
- Alternatively, you can create your own pdf of the item numbers you want by using the Create Publication page (see FAQs page for instructions), however you will need to know all the item numbers that pertain to ortho – these are listed in the MBS Book under Category 7, Group C1.
Current list of ASO members who treat CL&P patients
Update on the Cleft Dental Working Group
Members may recall that a Cleft Dental Working Group was established in late 2018 to review all aspects of Medicare Cleft Palate Scheme. Kit Chan and Hugh McCallum were the orthodontists appointed to this Working Group and after considering the 62 Items listed under the Scheme, the Working Group came up with over 29 recommendations. The non-government members of the Working Group argued for an increase (above the normal CPI) to the Rebates available under the Scheme, however it was made clear this was not a priority of the Review.
Medicare was due to release final recommendations in early 2020. However, with the onset of COVID-19 the timeline for completing the Review is not known.