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MRCA Treatment Principles

Authoritative Version
M21/2004 Principles as made
The MRCA Treatment Principles set out the places at which, the circumstances in which, and the conditions subject to which, the Military Rehabilitation and Compensation Commission may accept financial liability for the treatment of current and former members of the Australian Defence Force (ADF) and for dependants of deceased members of the ADF.
Administered by: Veterans' Affairs
General Comments: The MRCA Treatment Principles were approved by the Minister for Veterans' Affairs on 16 December 2004: see Supporting Material.
Registered 09 Mar 2005
Tabling HistoryDate
Tabled HR08-Feb-2005
Tabled Senate08-Feb-2005
Date of repeal 30 Nov 2013
Repealed by MRCA Treatment Principles (No. MRCC 53/2013)
Table of contents.
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Dated this 6th day of December 2004
PART 1 — INTRODUCTION
1.2 Application of MRCA Private Patient Principles
1.3 Delegation
1.4 Interpretation
PART 2 — ENTITLEMENT TO TREATMENT
2.1 Treatment for entitled persons in Australia
2.2 Treatment for entitled persons residing or travelling overseas
2.3 Treatment of associated non-service injury or disease injuries or diseases
2.6 Referrals by the Vietnam Veterans’ Counselling Service
2.8 Loss of eligibility for treatment
PART 3 — COMMISSION APPROVAL FOR TREATMENT
3.1 Approval for treatment
3.2 Circumstances in which prior approval is required
3.3 Circumstances in which prior approval is not required
3.4 Other retrospective approval
3.5 Financial responsibility
4.2 Providers of services
4.3 Financial responsibility
4.4 Referrals
4.5 Referrals by medical specialists
4.6 Referrals to medical specialists in country or Territory areas
4.7 Referrals: prior approval
4.8 Other matters
PART 5 — DENTAL TREATMENT
5.1 Providers of services
5.2 Financial responsibility
5.3 Entitlement
5.4 Emergency dental treatment
5.5 Orthodontic treatment for children
5.6 General anaesthesia
5.7 Prescribing of pharmaceutical benefits by dentists
5.8 Other dental services
PART 6 — PHARMACEUTICAL BENEFITS
6.1 MRCA Pharmaceutical Benefits Scheme
6.2 Entitlement under the MRCA Pharmaceutical Benefits Scheme
PART 7 — TREATMENT GENERALLY FROM OTHER HEALTH PROVIDERS
7.1 Prior approval and financial responsibility for health services
7.2 Registration or enrolment of providers
7.3 Community nursing
7.3A MRCA Home Care Program
7.4 Optometrical services
7.5 Physiotherapy
7.6 Podi atry
7.7 Chiropractic and osteopathic services
7.8 Other services
PART 9 — TREATMENT OF ENTITLED PERSONS AT HOSPITALS AND INSTITUTIONS
9.1 Admission to a hospital or institution
9.2 Financial Responsibility For Treatment In Hospital
9.3 Nursing-home-type care
9.5 Convalescent care
9.6 Other matters
PART 10 — RESIDENTIAL CARE
10.1 Residential care arrangements
10.4 Payment of residential care amount for certain entitled members with dependants
PART 11 — THE PROVISION OF REHABILITATION APPLIANCES
11.1 Rehabilitation Appliances Program
11.2 Supply of rehabilitation appliances
11.3 Restrictions on the supply of certain items
11.4 Visual aids
11.5 Hearing aids
11.6 Other rehabilitation appliances
11.7 Repair and replacement
11.8 Treatment aids from hospitals
11.9 Provision of aids and appliances for accident prevention and personal safety
PART 12 — OTHER TREATMENT MATTERS
12.1 Ambulance transport
12.2 Treatment under Medicare
12.4 Prejudicial or unsafe acts or omissions by patients
12.6 Recovery of moneys
MRCA
1 January 2005

Military Rehabilitation and Compensation Act 2004

Section 286

 

MRCA Treatment Principles

Instrument No. M 21 of 2004__________________________________________

 

 

Dated this         6th                 day of    December                       2004

 

 

 

 

_______________________

MARK SULLIVAN

CHAIR

___________________

IAN CAMPBELL

MEMBER

_____________________

SIMON HARRINGTON

MEMBER

 

 

 

_______________________

BARBARA BENNETT

MEMBER

 

 

 

 

_____________________

BRIAN ADAMS

MEMBER

 


Table of provisions

 

 

PART 1 — INTRODUCTION............................................................................................ 5

1.2          Application of MRCA Private Patient Principles........................................... 5

1.3          Delegation................................................................................................... 6

1.4          Interpretation............................................................................................... 6

PART 2 — ELIGIBILITY FOR TREATMENT................................................................... 19

2.1          Treatment for entitled persons in Australia.................................................... 19

2.2          Treatment for entitled persons residing or travelling overseas......................... 19

2.3          Treatment of associated non-service injury or disease injuries or diseases...... 20

2.8          Loss of eligibility for treatment...................................................................... 21

PART 3 — COMMISSION APPROVAL FOR TREATMENT.......................................... 22

3.1          Approval for treatment................................................................................ 22

3.2          Circumstances in which prior approval is required........................................ 22

3.3          Circumstances in which prior approval may not be required.......................... 25

3.4          Other retrospective approval....................................................................... 25

3.5          Financial responsibility................................................................................. 26

PART 4 — MEDICAL PRACTITIONER SERVICES........................................................ 29

4.1          Local Medical Officer or other GP Scheme.................................................. Error! Bookmark not defined.

4.2          Providers of services................................................................................... 29

4.3          Financial responsibility................................................................................. 30

4.4          Referrals by Local Medical Officer or other GPs.......................................... 32

4.5          Referrals by medical specialists.................................................................... 32

4.6          Referrals to medical specialists in country or Territory areas.......................... 32

4.7          Referrals: prior approval.............................................................................. 32

4.8          Other matters.............................................................................................. 33

PART 5 — DENTAL TREATMENT................................................................................... 34

5.1          Providers of services................................................................................... 34

5.2          Financial responsibility................................................................................. 34

5.3          Eligibility...................................................................................................... 34

5.4          Emergency dental treatment......................................................................... 35

5.5          Orthodontic treatment for children................................................................ 35

5.6          General anaesthesia..................................................................................... 35

5.7          Prescribing of pharmaceutical benefits by dentists......................................... 36

5.8          Other dental services................................................................................... 36

PART 6 — PHARMACEUTICAL BENEFITS.................................................................... 37

6.1          MRCA Pharmaceutical Benefits Scheme...................................................... 37

6.2          Eligibility under the MRCA Pharmaceutical Benefits Scheme........................ 37

PART 7 — TREATMENT GENERALLY FROM OTHER HEALTH PROVIDERS........... 38

7.1          Prior approval and financial responsibility for health services......................... 38

7.2          Registration or enrolment  of providers......................................................... 39

7.3          Community nursing...................................................................................... 39

7.3A       MRCA Home Care Program....................................................................... 40

7.4          Optometrical services.................................................................................. 44

7.5          Physiotherapy.............................................................................................. 45

7.6          Podiatry...................................................................................................... 45

7.7          Chiropractic and osteopathic services.......................................................... 48

7.8          Other services............................................................................................. 48

PART 9 — TREATMENT OF ENTITLED PERSONS AT HOSPITALS AND INSTITUTIONS     49

9.1          Admission to a hospital or institution............................................................. 49

9.2          Financial responsibility................................................................................. 50

9.3          Nursing-home-type care.............................................................................. 52

9.5          Convalescent care....................................................................................... 53

9.6          Other matters.............................................................................................. 53

PART 10 — RESIDENTIAL CARE.................................................................................... 54

10.1        Residential care arrangements...................................................................... 54

10.4        Payment of residential care amount for certain members with dependants...... 54

PART 11 — THE PROVISION OF REHABILITATION APPLIANCES........................... 58

11.1        Rehabilitation Appliances Program............................................................... 58

11.2        Supply of rehabilitation appliances................................................................ 58

11.3        Restrictions on the supply of certain items..................................................... 59

11.4        Visual aids................................................................................................... 60

11.5        Hearing aids................................................................................................ 61

11.6        Other rehabilitation appliances..................................................................... 63

11.7        Repair and replacement............................................................................... 63

11.8        Treatment aids from hospitals....................................................................... 64

11.9        Provision of aids and appliances for accident prevention and personal safety. 64

PART 12 — OTHER TREATMENT MATTERS................................................................. 66

12.1        Ambulance transport................................................................................... 66

12.2        Treatment under Medicare........................................................................... 66

12.4        Prejudicial or unsafe acts or omissions by patients........................................ 66

12.6        Recovery of moneys.................................................................................... 67

 


Index

 


accident, 53, 54

acute care certificate, 7, 43

Aged Care Act 1997, 45

ambulance, 19, 21, 55

attendant care, 7

audiology, 34, 50

Australian Hearing Service, 21

Australian Medical Association Ltd, 12

care plan, 9, 12, 35, 37

carer, 7, 11, 13, 40

child, 9, 31, 32, 61

Commission-funded treatment, 7

community nursing, 34, 35, 36

community services, 7, 59, 60

compensation, 7, 49, 55

contracted private hospital, 7, 43

convalescent admission, 7

convalescent care, 44

counselling, 17

country area, 7, 52

service injury or disease, 14, 61

delegation, 7, 63

dental prosthetist, 8, 30

dental schedules, 8, 30, 63

dental specialist, 8, 30, 32

dental treatment, 19, 21, 30, 31, 32

dentists, 24

determination, 9, 17

determined condition, 8, 14

determined residential care condition, 8, 26, 30

Diagnostic and Statistical Manual of Mental Disorders, 16

dietetics, 34

Local Medical Officer or other GP, 8, 11, 25

elective surgery, 8, 18, 29, 41

entitled person, 8, 22, 23, 40, 56

emergency, 8, 15, 21, 22, 31, 40, 55

entitled person, 9, 13, 17, 25, 26, 28, 29, 30, 31, 34, 35, 36, 40, 41, 43, 44, 49, 50, 52, 53, 55, 56, 61, 63

episode of care, 9, 36

friendly society, 7, 24, 29

Gold Card, 32, 33

Gold Card, 9, 15, 26, 31, 45

guide dog, 48

Guidelines for Nurses, 35

health insurance, 7, 22, 24, 29, 43

Health Insurance Act 1973, 7, 11, 12, 41, 43, 45

Health Insurance Commission, 9

health provider, 9, 11, 12, 23, 34

hearing aids, 50

herbalists, 39

high level of residential care, 45

home, 7, 11, 18, 35, 40, 43, 56, 59, 63

homeopaths, 39

hospital maintenance charges, 41, 43, 63

hydrotherapy, 12, 34, 36

inoculation, 29

inpatient, 21, 40, 41, 43, 44, 53

in-vitro fertilisation, 29

iridologists, 39

Local Dental Officer, 30, 32, 63

Local Dental Officer Scheme, 30, 63

Local Medical Officer or other GP, 8, 11, 21, 25, 26, 35, 39

Local Medical Officer or other GPs, 21, 22, 25, 26, 28, 29, 30, 36, 63

low level of residential care, 45

masseurs, 39

medical certificate, 24, 29

medical practitioner, 7, 11, 15, 16, 25, 32, 43

Medicare, 11, 22, 23, 24, 25, 26, 29, 36, 55

Medicare Benefits Schedule, 11, 23, 25, 29

Memorandum of Understanding, 8, 12, 22, 25

metropolitan area, 7, 21

minor procedure, 12, 18, 29

misrepresentation, 56

mistake, 56

multi-phasic screening, 29

naturopaths, 39

Notes for Nurses, 63

nursing home, 43, 63

occupational therapy, 34

offsetting moneys, 57

optometrist, 13

optometrists, 36, 49

outpatient, 18, 40, 53

outpatient service, 12

overseas, 15, 22, 29, 46, 52, 63

partner, 29, 40

pathology, 29

PBS, 12, 32, 52

personal safety, 53, 54

physiotherapists, 24

physiotherapy, 12, 19, 21, 34, 36

podiatrist, 24, 36

podiatry, 19, 21, 34, 36

pregnancy, 28

prior approval, 6, 12, 18, 19, 21, 22, 28, 29, 30, 31, 32, 34, 36, 40, 41, 44, 47, 49, 52, 53, 55

private hospital, 12, 18, 21, 40, 41, 43

prostheses, 43

provider number, 35, 36, 37, 39

Provision of aids and appliances for accident prevention and personal safety, 53

psychiatric illness, 43

psychiatric institution, 12, 43

psychology, 34

psychotherapy, 28

public hospital, 6, 12, 18, 21, 40, 41, 43

radiology, 29

recognized hospital, 12

recovery, 56, 57

registration, 7, 8, 35, 36, 49

rehabilitation appliance, 15, 19, 47, 49, 52

MRCA Private Patient Principles, 6, 18, 21, 28, 29, 40, 41

residential care, 11, 13, 15, 19, 34, 44, 45, 46, 58

RESIDENTIAL CARE, 45

residential care amount, 13, 46

residential care subsidy, 13, 44, 45, 46, 58

respite, 11, 13, 18, 40, 58, 59, 60

MPBS, 12, 33, 52

MPPPs, 6, 13

Schedule of Prescribable Items, 13, 36, 49, 50

sequelae, 16

social work, 34

specialist, 8, 11, 18, 21, 25, 26, 28, 29, 30, 32, 36

spectacles, 49, 50, 53

speech pathology, 34

stoma, 52

surgical appliances, 47

theatre fees, 12, 43

travel, 15, 29

vaccination, 29

vehicle, 48

visual aids, 19, 36, 49

wheelchairs, 48

White Card, 31, 32, 33

White Card, 14, 15, 26, 31, 45

written authorisation, 14, 15, 31


 


 

 

 

MILITARY REHABILITATION AND COMPENSATION COMMISSION

 

 

Section 286 Military Rehabilitation and Compensation Act 2004

 

MRCA Treatment Principles

Instrument N° M 21 of 2004

 

PART 1 — INTRODUCTION

1.1.1       This Instrument is known as the MRCA Treatment Principles and is prepared by the Military Rehabilitation and Compensation Commission (Commission) under section 286 of the Act.  The MRCA Treatment Principles set out the places at which, the circumstances in which, and the conditions subject to which, a particular kind or class of treatment may be provided for entitled persons under Part 3 of Chapter 6 of the Act and are to be read subject to the Act.

 

1.1.2       The MRCA Treatment Principles state the policies under which the Commission may accept financial responsibility for the cost of treatment for persons entitled to treatment under the Act.

Note:       Consistent with the Act, treatment extends beyond medical treatment and encompasses social and domestic assistance.

 

1.1.3       The MRCA Treatment Principles commence on 1 January 2005 after the commencement of the Military Rehabilitation and Compensation Treatment (Revocation) Determination (Instrument No. M20 of 2004).

 

1.2       Application of MRCA Private Patient Principles

1.2.1       The MRCA Private Patient Principles (the MPPPs), determined by the Commission under paragraph 286(1)(b) of the Act, apply in all States and Territories

 

1.2.2       A provision of the MRCA Treatment Principles does not apply if it is inconsistent with the MPPPs.

 

1.2.3       Nothing in these Principles is to be taken to require prior approval for admission at a public hospital in a State or Territory.

1.3       Delegation

1.3.1        The Commission may delegate all or any of its powers under the Principles (except this power of delegation) in the same manner, and subject to the same conditions, that it may delegate all or any of its powers under the Act.

Note: section 384 of the Act sets out the circumstances in which the Commission may delegate its powers.

 

1.4       Interpretation

1.4.1       In these Principles, unless a contrary intention appears:

 

“Act” means the Military Rehabilitation and Compensation Act 2004.

 

“acute care certificate means a certificate given by a medical practitioner in similar form to the acute care certificate provided for in section 3B of the Health Insurance Act 1973 to the extent that the provisions of that section are applicable.

 

"approved provider" means a State, Territory or Local Government, or incorporated organisation, or person, that has entered into an arrangement with the Commission for the provision of a Home Care service (category A) or a Home Care service (category B) or a limited MHC-type service, to an entitled person, whether by the approved provider or a sub-contractor engaged by it.

 

“attendant care means assistance with essential daily activities, such as bathing, dressing and eating.

 

“carermeans a person who provides ongoing care, attention and support for a severely incapacitated or frail person to enable that person to continue to reside in his or her home, and is not limited to a person who is receiving a carer service pension.

 

 

“Centre for Military and Veterans’ Healthmeans the entity in the University of Queensland, Herston Campus, operated by the Board of Management.

 

“CMVH treatment” means action taken with a view to maintaining a member in physical or mental health and includes:

 

(a)           training members of the Defence Force in the health care disciplines that could benefit the health of a member;

(b)           conducting research into injuries or diseases suffered by members of the Defence Force or into the state of health generally of such members with the resulting knowledge being applied to the benefit of the health of a member;

(c)           improving communication on health care matters between members of the Defence Force who are staff-managers and a member; and

(d)           conducting health-care policy research with the outcomes of that research being applied to the benefit of the health of a member.

 

Note: under section 13 of the Act treatment can be action taken with a view to maintaining a person in physical or mental health.

 

“Commission” means the Military Rehabilitation and Compensation Commission.

 

"Commission-funded treatment" means treatment for which the Commission may accept financial responsibility.

Note: although the Commission may accept financial responsibility for treatment, actual payment for that treatment is made by the Commonwealth.  See paragraph 423(c) of the Act.

 

"community nursing services" means the community nursing services provided to an entitled person, in respect of which the Commission will accept financial responsibility for under Part 7 of the Principles.

 

"community nursing provider" means a health provider that has a contract with the Commission and, or, the Department, to provide community nursing services to entitled persons.

 

“community services means services provided by Commonwealth, State, Territory or local government authorities or agencies (other than the Department of Veterans’ Affairs or the Repatriation Commission) and other community agencies (whether or not funded in whole or in part by a government).

 

“contracted private hospital means a private hospital with which the Commission has entered into arrangements for the care and welfare of entitled persons.

 

“convalescent admission means a short period of medically prescribed convalescence for a entitled person who is recovering from an acute illness or an operation.

 

"co payment" means an amount of money an approved provider or a sub-contractor is permitted to charge an entitled person, pursuant to an arrangement between the approved provider and the Commission, in respect of a Home Care service (category A).

 

“country area” means that part of the State outside the metropolitan area of the capital city of that State, determined by the Repatriation Commission to be a country area under paragraph 80(2)(b) of the Veterans' Entitlements Act 1986.

 

“dental prosthetist means a person, however described, authorised under a law of a State or a Territory, to carry out the work of dental prosthetics without a written work order from a dentist or other person who may lawfully give a written work order for that purpose.

 

“dental schedulesmeans the documents known as Dental Schedules A, B and C and the Dental Prosthetist Schedule that:

 

(a)        list the dental services provided or arranged by the Commission; and

(b)        are deemed to have been prepared by the Commission (see Schedule 1 of the Principles).

 

“dental specialist means a qualified dental practitioner who:

 

(a)        is registered with a Dental Board of the State or Territory in which he or she practises; and

 

(b)        has obtained an appropriate higher qualification; and

 

(c)        has been recognised as a specialist in the particular field by:

 

(i)         a Dental Board of the State or Territory in which he or she practises, where the Dental Board of the State or Territory has available a mechanism for such recognition; or

 

(ii)        another appropriate body mutually agreed in advance with the Australian Dental Association Incorporated.

 

“Department” means the Commonwealth as represented by the Department of Veterans’ Affairs.

 

“Department of Health” means the Commonwealth Department of State, however named, that from time to time is responsible for the administration of the National Health Act 1953 and the Aged Care Act 1997.

 

"dependent eligible young person" has the same meaning as "dependent child" in the Social Security Act 1991.

 

"Domestic Assistance" means the service under the MRCA Home Care                Program consisting of:

 

(a)     assistance with domestic chores, including assistance with cleaning, dishwashing, clothes washing and ironing, shopping and bill paying; and

(b)     help with meal preparation where this is not the primary focus of the occasion of the service; and

(c)     in remote areas, activities such as collecting firewood.

 

“elective surgery means any non-urgent surgical procedure performed for diagnostic or therapeutic purposes.

 

"eligible young person" has the meaning it has in section 5 of the Act.

 

“emergency means a situation where a person requires immediate treatment in circumstances where there is serious threat to the person’s life or health.

 

"emergency short term home relief" means care provided to an entitled person in his or her home on the following conditions:

 

                      (a)           the person or the person's carer is unable to provide care due to sudden and unforeseen              circumstances; and

 

                      (b)           the period for which the care is provided does not exceed 72 hours (episode) per            emergency except that, if the entitled person requires further care within 24 hours after the              end of the previous episode in an emergency, and obtains prior approval, a further episode                 of care (up to 72 hours) may be provided in that emergency; and

                                                        

                      (c)           the cumulative period of the care provided to the entitled person did not exceed 216 hours           in a Financial year.

 

                      Note (1):  emergency short term home relief is not relevant to the calculation of residential care amounts for residential care or residential care (respite).

                               

“entitled member" means a member or former member as defined in section 5 of the Act who is or was entitled to treatment under Part 3 of Chapter 6 of the Act.

 

“entitled person means a person who is entitled to treatment under Part 3 of Chapter 6 of the Act.

 

“wholly dependent partner” or “wholly dependent partnerer” means a wholly dependent partner as defined in section 5 of the Act.

 

"episode of care" means services provided to a patient by a health provider that:

 

                (a) have been detailed in a patient care plan;

 

                (b) are characterised by continuity of treatment or provision of service;

 

                      and an episode of care arises:

 

                (c) every time a service provider sees a new patient; or

 

                (d) where a service provider has not seen a patient for some time and therefore no continuity of service                          can be provided, and the original patient care plan is no longer applicable or                                      appropriate.

 

“exceptional case process” means the process whereby the Commission may accept financial liability for community nursing services provided to an entitled person who, due to dependency or complex needs, requires community nursing services which, in the opinion of the Commission, fall significantly outside those referred to in any arrangement between the Commission and a community nursing provider.

 

Note: paragraph 3.5.1 (after paragraph (f)) enables the Commission, in exceptional circumstances to, among other things, accept financial liability for fees higher than those set out in an arrangement.

 

"excluded service" means a service within the scope of the Home and Community               Care Program established under the Home and Community Care Act 1985, as amended from time to   time, that is commonly known as:

 

                (a) domestic assistance or personal care; or

                (b) home maintenance; or

                (c) respite care;

                                               

                Note (1): for the purposes of this definition, "respite care" does not include centre-based day care (also called "day centre respite" or adult day activity centres").

               

                Note (2): the intention is that Home Care services categories A and B are mutually exclusive.

 

"exempt amount" means an amount of money not payable by an entitled person in            

                respect of any Home Care service (category A) provided to the entitled person by an approved     provider, because the entitled person is an exempt entitled person.

 

"exempt entitled person" means, in relation to the provision of any Home             

                Care service (category A) to an entitled person, an entitled person who:

 

(a) has a dependent eligible young person; or

       

Note: under the Acts Interpretation Act 1901 the singular includes the plural meaning a person can have more than one dependent eligible young person.

 

(b) is a person who, in the opinion of the Commission, is experiencing severe financial hardship or who could experience severe financial hardship if the person was to make a payment in respect of the service; or

       

(c) is in receipt of an income support payment at the maximum rate and does not earn, derive or receive ordinary income exceeding $40 per fortnight.

                               

                                                                Note: the Commission may allow exemption from payment for a period or until the occurrence of an event.

 

“Gold Card means the identification card described as the Repatriation Health Card - For All Conditions and provided to a person who is entitled under the Act to treatment, subject to these Principles, for all injuries or diseases.

 

"Health Insurance Commission" means the Health Insurance Commission established under the Health Insurance Commission Act 1973.


Leave 1 page space as amendment divider


 

"health provider means a person who provides treatment services.

 

"high level of residential care" has the meaning given in clause 1 of Schedule 1 to the Aged Care Act 1997.

Note:       Clause 1 of Schedule 1 to the Aged Care Act 1997 provides that: ‘high level of residential care means a level of residential care corresponding to a classification level applicable to residential care (other than a classification level applicable only to respite care) that is not lower than the mid-point of all such classification levels that could apply to residential care.

The phrases ‘classification level’ and ‘respite care’ used in this definition are also defined in the Aged Care Act 1997.

This definition does not exclude entitled persons in respite care or convalescent care.

 

“home includes:

 

(a)        the premises, or part of the premises, where the person normally resides; or

 

(b)        a share house where the person normally resides;

 

but does not include:

 

                   (c)        a hospital; or

 

(d)            the premises where the person is receiving residential care.

 

              Note:   ‘residential care is also defined in paragraph 1.4.1.”.

 

"Home and Community Care Program service" means a service of Home and Community Care provided under the auspices of the Home and Community Care Act 1985.

 

"Home and Garden Maintenance" means the service, under the MRCA Home Care Program, of maintaining the home, garden or yard of an entitled person, and includes:

 

(a)            assistance with minor maintenance and minor repair of the home (e.g changing light bulbs, minor carpentry, minor painting, replacing tap washers, but not the supply of replacement items), garden or yard to keep the home, garden or yard safe and habitable;

(b)            lawn mowing;

 

but does not mean:

 

(c)        tree felling or tree removing or other major tasks related to a garden or yard;

(d)        provision of materials.

 

Note: recipients of MRCA Home Care services will be expected to supply materials used in home maintenance, eg replacement light bulbs and tap washers.  Service providers will be required to provide any equipment needed, eg garden tools.

 

"Home Care service (category A)" means the provision of Domestic Assistance, Personal Care, Home and Garden Maintenance or Respite Care to an entitled person pursuant to the MRCA Home Care Program.

 

"Home Care service (category B)" means the provision of treatment, pursuant to the MRCA Home Care Program, that would satisfy the description of a service within the scope of the Home and Community Care Program established under the Home and Community Care Act 1985, as amended from time to time, but does not mean the provision of treatment, pursuant to the MRCA Home Care Program, that would satisfy the description of an excluded service.

 

"income support payment" has the same meaning it has in the Social Security Act 1991, save that it includes an income support supplement under the VEA;

 

Note: As at 1 January 2001 income support payments were:(a) a social security benefit; (b) a job search allowance; (c) a social security pension; (d) a youth training allowance; (e) a service pension.

 

“in-home respite means care provided to a person in his or her own home for a maximum of 196 hours in a Financial year to provide rest or relief from the role of caring:

 

(a)        to the person; or

 

(b)        to the person’s carer;

 

Note: in-home respite is not relevant to the calculation of residential care amounts for residential care or residential care (respite).

 

“inpatient” means a person formally admitted for treatment by a hospital.

 

"limited MHC-type service" means a service identical to Domestic Assistance or Home and Garden Maintenance, provided, or to be provided, by an approved provider to a person eligible to receive a limited MHC-type service.

 

"Local Medical Officer" or "LMO" means a medical practitioner who, under paragraph 285(1)(c) of the Act, has entered into an arrangement with the Commission whereby the medical practitioner will provide medical treatment to entitled persons.

 

"low level of residential care" means a level of residential care that is not a high level of residential care.

 

“medical practitionerhas the same meaning as “medical practitioner” has in the Health Insurance Act 1973.

 

“medical specialist means a medical practitioner who is recognised as a consultant physician or as a specialist, in the appropriate specialty, for the purposes of the Health Insurance Act 1973.

 

"Medicare benefit", in relation to a medical attendance or medical procedure, means the benefit payable in respect of that attendance or procedure under Part II of the Health Insurance Act 1973.

 

“Medicare Benefits Schedulemeans:

 

(a)        Schedule 1 to the Health Insurance Act 1973 as substituted by regulations made under subsection 4(2) of that Act; and

 

(b)        Schedule 1A to the Health Insurance Act 1973 as substituted by regulations made under subsection 4(2) of that Act; and

 

(c)        the table of diagnostic imaging services prescribed under subsection 4AA(1) of that Act as in force from time to time.

 

"member" has the meaning it has in the Act save that it includes former member.

 

"Memorandum of Understanding of 1995" means the Memorandum of Understanding between the Commonwealth of Australia as represented by the Department of Veterans' Affairs, the Repatriation Commission and the Australian Medical Association Ltd, relating to the provision of medical services by Local Medical Officers to entitled persons, dated 10 December 1995.

 

“minor procedure means a surgical procedure that:

 

(a)        does not involve hospitalisation or theatre fees; and

 

(b)        is of a type that is undertaken routinely in doctors’ and specialists’ rooms; and

 

(c)        does not require general anaesthesia; and

 

(d)        is not undertaken in a private day facility centre.

 

“MPPPs means the MRCA Private Patient Principles determined by the Commission under paragraph 286(1(b) of the Act.

 

"MRCA Access Payment" means:

(a) an amount of $4.00 payable by the Department to an LMO for a medical service (other than a Level A attendance) provided by the LMO to an entitled person ¾ where that service is provided pursuant to the LMO's arrangement with the Commission; or

(b) an amount of $5.50 payable by the Department to an LMO for a medical service that is a Level A attendance provided by an LMO to an entitled person ¾ where that service is provided pursuant to the LMO's arrangement with the Commission;

being an amount in addition to any amount otherwise payable by the Department to an LMO for a medical service provided to an entitled person by the LMO pursuant to the LMO's arrangement with the Commission.

 

"MRCA Home Care Program" means the treatment program under which the Commission ensures the provision of care and assistance services to entitled persons who are frail, or who have disabilities, with the aim of maintaining the independence of those people, allowing them to remain in their own home for as long as possible, and reducing avoidable illness and injury, and is comprised of paragraphs 7.3A to 7.3A.22 (inclusive) of the Principles, and other relevant paragraphs in the Principles, and the arrangements under section 285 of the Act in support thereof.

 

MHC assessment agency” means a person to whom the Commission has delegated its power to assess whether a person needs a Home Care service (category A), or a Home Care service (category B), under the MRCA Home Care Program.

 

"MRCA Pharmaceutical Benefits Scheme" means the scheme determined by the Commission under paragraph 286(1)(c) of the Act.

 

"MRCA Private Patient Principles" means the principles in the determination made by the Commission under paragraph 286(1)(b) of the Act.

 

"ordinary income" has the same meaning it has under the definition of "ordinary income" in the "Social Security Act 1991" including where terms in that meaning are further defined save that "ordinary income" does not include a payment of Income support supplement.

 

Note: Income support supplement is described in Part IIIA of the VEA.

 

“other GP” means a medical practitioner who provides treatment to an entitled person otherwise than under a written contract with the Commission or the Department (on behalf of the Commission) and who does not, directly or indirectly, impose any charge on the entitled person in relation to that treatment but instead charges the Commission, the Department or the Health Insurance Commission for the treatment at rates set out in these Principles.

 

“outpatient service means a health service or procedure provided by a hospital but not involving admission to the hospital.

 

"patient care plan" means a document that is completed by a health provider who provides a service to a patient and that contains details of:

 

                (a)           the patient's medical history;

 

                (b)           the injury or disease in respect of which the service is to be provided;

 

                (c)           the proposed management of the injury or disease; and

 

                (d)           an estimation of the duration and frequency of the service to be provided.

 

"Personal Care" means the service under the MRCA Home Care Program           consisting of assistance with daily self care tasks, such as eating, bathing, toileting, dressing, grooming, getting in and out of bed, and moving about the house.

 

“PBS means the Pharmaceutical Benefits Scheme authorised under the National Health Act 1953.

 

“physiotherapy includes hydrotherapy.

 

“Principles” means the MRCA Treatment Principles.

 

“prior approval means that approval for the assumption by the Commission of the whole, or partial, financial responsibility for certain treatment must be given by the Commission before that treatment is commenced or undertaken.

 

“private hospital means premises that have been declared specifically as private hospitals for the purposes of the Health Insurance Act 1973.

 

"proscribed amount" means, in relation to the MRCA Home Care Program:

 

(a)            subject to paragraph (b), an amount of money that if paid by an entitled person would mean the entitled person has paid in respect of a Home Care service (category A) comprised of Domestic Assistance provided to that entitled person by any approved provider or by any sub-contractor during a week or part thereof, an amount exceeding $5;

               

Note: for the purpose of ascertaining if an amount of money is a proscribed amount where the amount demanded, received or assigned is in respect of a service (s) provided during two or more weeks, without the service (s) being related to the particular week in which the service(s) was delivered, the amount             shall be apportioned pro rata to those weeks.

 

(aa)      subject to paragraph (b), an amount of money that if paid by an entitled person would mean the entitled person has paid in respect of a Home Care service (category A) comprised of Home and Garden Maintenance, provided to that entitled person by any approved provider or by any sub-contractor during the relevant period referred to in paragraph 7.3A.3 (2) of the Principles, an amount exceeding $75;

 

Note (1): the "relevant period" is a period of 12 months.

Note (2): under paragraph 7.3A.8(a) of the Principles, an entitled person cannot be charged more than $5 per hour of service.

 

(b)            an amount of money that if paid by an entitled person receiving a Home Care service (category A) that was similar to a Home and Community Care Program service provided to the person immediately before 1 January 2001 would mean the entitled person has paid in respect of the Home Care service (category A) provided to that entitled person by any approved provider or by any sub-contractor, an amount exceeding the maximum amount the person could have been required to pay over a particular period in respect of the Home and Community Care Program service formerly provided to the person that was similar to the Home Care service (category A) provided to the entitled person;

               

Note: for the purpose of ascertaining if an amount of money is a proscribed amount where the amount demanded, received or assigned is in respect of a service (s) provided during two or more weeks, without the service (s) being related to the particular week in which the service(s) was delivered, the amount shall be apportioned pro rata to those weeks.

 

(c)            subject to paragraph (b), an amount of money that if paid by an entitled person would mean the entitled person has paid, in respect of a Home Care service (category A) comprised of Personal Care provided to that entitled person by any approved provider or by any sub-contractor during a week or part thereof, an amount exceeding $10;

                               

                                Note: for the purpose of ascertaining if an amount of money is a proscribed amount where the amount demanded, received or assigned is in respect of a service (s) provided during two or more weeks, without the service (s) being related to the particular week in which the service(s) was delivered, the amount             shall be apportioned pro rata to those weeks.

 

(d)            an amount of money in respect of Respite Care provided, or to be provided, by an approved provider or by a subcontractor, to an entitled person;

         

          Note: the intention is that any amount charged for Respite Care is a proscribed amount regardless of whether it would or would not exceed $5 per hour of service.

 

(e)            an amount of money in respect of a Home Care service (category A) provided or to be provided to an entitled person that was a similar service to a Home and Community Care Program service the entitled person received immediately before 1 January 2001 and in respect of which the entitled person had not been required to pay a charge;

                               

                                Note: the intention is that any amount charged for a service similar to a free former Home and Community Care Program service previously received is a proscribed amount regardless of whether it would or would not exceed $5 per hour of service.

 

(f)             an amount of money, in respect of a Home Care service (category A) provided or to be provided to an entitled person that was a similar service to a Home and Community Care Program service the entitled person received immediately before 1 January 2001, that exceeds any amount of money the entitled person had been required to pay in respect of the Home and Community Care Program service;

         

          Note: It is the intention that any amount charged for a service similar to a Home and Community Care Program service previously received that is over and above the amount the entitled person previously paid in respect of the Home and Community Care Program service is a proscribed amount notwithstanding that the sum of the amounts that could and could not be charged did not exceed $5 per hour of service.  The limitation on the maximum amount a person could be required to pay in (a), (aa) and (b) above applies to this situation (maximum amount payable over a period).

 

(g)            an exempt amount;

         

          Note: the intention is that an exempt amount remains a proscribed amount and therefore not chargeable notwithstanding it would or would not exceed $5 per hour of service.

 

"provision of a Home Care service (category A) to an entitled person by an approved provider" includes the situation where an approved provider engages a sub-contractor to provide a Home Care service (category A) to an entitled person.

 

"provision of a Home Care service (category B) to an entitled person by the Commission" includes the situation where the Commission engages a sub-contractor to provide a Home Care service (category B) to an entitled person.

 

public hospital has the same meaning as “recognized hospital” as defined in the Health Insurance Act 1973.

Note:         Section 3 of the Health Insurance Act 1973 defines “recognized hospital” in terms of hospitals recognized for the purposes of the Medicare agreement, or hospitals declared by the Minister who administers the Health Insurance Act 1973 to be recognized hospitals.

 

“MRCA Pharmaceutical Benefits Scheme means the Scheme determined under paragraph 286(1)(c) of the Act.

 

"Repatriation Commission" means the body corporate continued in existence by section 179 of the Veterans' Entitlements Act 1986;

 

"residential care" means personal care or nursing care, or both personal care and nursing care, that is provided to a person in a residential care facility in which the person is also provided with:

(a)           meals and cleaning services; and

 

(b)                 appropriate staffing, furnishings, furniture and equipment for the

                provision of that care and accommodation;

 

but does not include any of the following:

 

(c)           care provided to a person in the person’s private home; or

 

(d)           care provided in a hospital or psychiatric facility; or

 

(e)           care provided in a residential facility that primarily provides care to people who are not frail and aged.

 

"residential care amount" means:

 

(a)           in relation to a resident of a hospital — an amount determined under the Health Insurance Act 1973 to be the resident contribution applicable under that Act to a nursing-home-type patient of that hospital; or

 

(b)           in relation to a person in receipt of a high level of residential care — an amount equivalent to the maximum daily amount of resident fees worked out under Division 58 of the Aged Care Act 1997;or

Note:         ‘maximum daily amount of resident fees’ is defined in section 58-2 of the Aged Care Act 1997.

Note:      ‘standard resident contribution’ is defined in sections 58-3 and 58-4 of the Aged Care Act 1997 and does not include the ‘daily income tested reduction’ (defined in sections 44-21 to 44-23 of the Aged Care Act 1997. The effect of this is that for the purposes of determining the Commonwealth’s liability under the Act the income testing provisions of the Aged Care Act 1997 do not apply.

 

(d)           in relation to an entitled person awarded the Victoria Cross who is receiving or received a high level of residential care — an amount equivalent to the sum of:

 

                                                (i)            the standard resident contribution worked out under Division 58 of the                  

                                                                Aged Care Act 1997, as that amount forms part of the maximum daily                     

                                                                amount of resident fees; and

                                                (ii)           any care fee payable by the entitled person, in respect of the residential                               

                                                care, that is calculated by reference to the person's income.

                               

                   Note: if a standard resident contribution is payable daily because it forms part of the

                                maximum daily amount of resident fees a person is to pay, then the Commission's

                                financial responsibility for the standard resident contribution is for that contribution as

                                it is incurred daily.

 

"residential care (respite)" means residential care provided as respite and includes residential care (28 day respite).

 

"residential care (28 day respite)" means residential care provided as respite for up to 28 days in a Financial year pursuant to the MRCA Home Care Program.

 

"residential care subsidy" means an amount worked out under Chapter 3 of the Aged Care Act 1997 that is payable by the Commonwealth in respect of an entitled person’s residential care according to the classification level determined under Part 2.4 of that Act.

 

“respite means a rest, break or relief for a person’s carer or a person caring for himself or herself, from the role of caring.

 

"Respite Care" means the service under the MRCA Home Care Program consisting of in-home respite, residential care (28 day respite) or emergency short term home relief.

 

“respite admission” means the admission of an entitled person to an institution to provide rest or relief for that person’s carer, or admission to an institution of an entitled person caring for himself or herself.

 

"Rural Enhancement Scheme" means the scheme jointly established by the Commission (under section 285 of the Act) and the Repatriation Commission, in consultation with the Australian Medical Association Ltd, and which has the following features:

 

(a)           LMOs who provide medical services (services) to entitled persons under the Rural Enhancement Scheme (Scheme) receive higher payments (as set out in the Principles) from the Department for those services than they would receive if the services were not provided under the Scheme;

 

(b)           the Scheme only applies to LMOs who provide medical services to entitled persons at certain rural public hospitals (identified rural hospitals);

 

(c)           an identified rural hospital is a hospital at which a medical practitioner may provide a medical service (service) to the public and receive from the state or territory government that, respectively, administers the state or territory in which the hospital is located, an extra amount (extra amount) for that service.

 

(d)           the extra amount is an amount representing the difference between the amount the State or Territory actually pays the medical practitioner for the service and the fee for the service listed in the Medicare Benefits Schedule.

 

                Note: as at 1 January 2005 the Rural Enhancement Scheme only operated in NSW, Vic, SA and WA.

 

“Schedule of Prescribable Itemsmeans the schedule prepared by the Commission under paragraph 7.4.1 that lists the products that may be supplied under these Principles by optometrists and other optical dispensers.

 

"service injury" has the meaning it has in section 5 of the Act.

 

"service disease" has the meaning it has in section 5 of the Act.

 

"sub-contractor" means, in relation to the MRCA Home Care Program, a State, Territory or Local Government, or incorporated organisation, or person, engaged by an approved provider or the Commission to provide a Home Care service (category A) or a Home Care service (category B), respectively, to an entitled person.

 

"VEA" means the Veterans' Entitlements Act 1986.

 

“service injury or disease” is to be read as including “service injury or disease” by force of section 81 of the Act.

 

"week" means the period from Sunday to Saturday, inclusive.

 

"White Card" means the identification card described as the Repatriation Health Card - For Specific Conditions and provided to a person who is eligible under the Act for treatment, subject to these Principles, of a service injury or a service disease and also means a written authorisation issued on behalf of the Commission under subparagraph 2.1.1(a)(iii) and provided to a person who is entitled under the Act for treatment.

 

1.4.2       In the MRCA Treatment Principles, if a Note follows a principle, paragraph or subparagraph, the Note is taken to be part of that principle, paragraph or subparagraph, as the case may be.


 

PART 2 — ENTITLEMENT TO TREATMENT

2.1       Treatment for entitled persons in Australia

2.1.1       Subject to these Principles, the Commission may provide or arrange for treatment in Australia of:

 

(a)        entitled persons who have been issued with:

 

(i)         a Gold Card; or

 

(ii)        a White Card; or

 

(iii)       a written authorisation issued on behalf of the Commission; and

 

2.2       Treatment for entitled persons residing or travelling overseas

2.2.1       Subject to these Principles, the Commission will accept financial responsibility for the treatment overseas of service injuries or service diseases only for:

 

(a)        a member who is resident overseas; or

 

(b)        a member who is travelling overseas.

 

2.2.2       Except where the Commission decides otherwise, the Commission will not accept financial responsibility under paragraph 2.2.1 for costs incurred in the treatment of a service injury or disease injury or disease while a member is temporarily absent from Australia unless, prior to departure, an office of the Department has been notified of the member's intention to travel.

 

2.2.3       Except in an emergency, financial responsibility under paragraph 2.2.1 will be limited to:

 

(a)           except in the cases of residential care or residential care (respite), the cost of treatment provided in             accordance with the mode and duration that would have been provided or arranged, under these          Principles, in Australia; or

 

(b)           except in the cases of residential care or residential care (respite), the cost of treatment provided by a         health authority or facility nominated by the Commission; or

 

(c)           in the case of residential care or residential care (respite) provided for a period to a member, whether          provided in an emergency or not the lesser of:

 

                (i) the amount charged the member; or

               

                (ii) the amount of residential care subsidy (at classification level 1 for residential care or at

                      classification level 3 for residential care (respite)) and the residential care amount (if any) that

                      would have been accepted by the Commission in respect of the member if the member had received

                      residential care or residential care (respite), as the case may be, at the classification level 1 or the

                      classification level 3, respectively, for the same period in Australia; or

                     

                      Note (1): Subject to the Principles, the Commission will not accept financial responsibility for medical or allied-health treatment applied to an injury or disease of a member that is not a service injury or a service disease.

                     

                      Note (3): "classification level 1" and "classification level 3" mean "residential care classification level 1"and "residential care classification level 3", respectively, under the Aged Care Act 1997.  By virtue of Part 10 of the Principles the Commission, in the first instance, rather than the Commonwealth, accepts financial responsibility for the provision of residential care and residential care (respite) under the Aged Care Act 1997 to entitled persons (the armed service community).

                     

                      Note (4): the "residential care amount", also commonly known as the "basic daily care fee" or "resident fee", is the amount to be worked out under section 58-3, or the amount to be worked out under subsection 58-4(1), of the Aged Care Act 1997 as amended from time to time, depending on which of those provisions applied to the circumstances of the member.

 

(d)           in the case of residential care (respite), the cost of that care (as worked out under paragraph (c)) for              only a maximum of 63 days in any Financial year.

 

Note (1):the intention is that the Commission will not accept any further financial responsibility for "a respite admission" in a Financial year where in that year the person had already spent 63 days in residential care as a respite admission.

               

                Note (2): for the purpose of calculating the number of days spent by a member in residential care (respite) in a Financial year, any day spent in residential care (respite) in Australia in that year is also to be taken into account.

 

2.2.5       Notwithstanding paragraphs 2.2.2 or 2.2.3, the Commission will not be responsible for treatment costs incurred by any person who travels overseas from Australia where a significant reason for that travel is to obtain treatment or rehabilitation appliances.

 

           No Overseas MRCA Home Care or HomeFront

 

2.2.8                       The Commission will not accept financial liability for the provision overseas of treatment under the MRCA Home Care Program or under the HomeFront Program.

 

Note:the HomeFront Program is the common name given to accident prevention and personal safety treatment provided under paragraphs 11.9.1 to and including paragraph 11.9.8 of the Principles.

 

2.3       Treatment of associated non-service injury or disease injuries or diseases

2.3.1       Subject to these Principles, the Commission will provide, arrange, or accept financial responsibility for treatment of an injury or disease that is not a service injury or a service disease to the extent that it is a necessary part of treatment for a service injury or service disease.

 

2.6       Referrals by the Vietnam Veterans’ Counselling Service

2.6.1       The Vietnam Veterans’ Counselling Service may refer its clients who are members to other counselling services.

 

2.6.2       The Commission will accept financial responsibility for counselling referred under paragraph 2.6.1 only where that referral is in accordance with guidelines prepared by the Commission.

Note:          The guidelines are prepared by the Commission after, and subject to, consideration of advice from the National Advisory Committee on the Vietnam Veterans’ Counselling Service.

 

2.7A    Centre for Military and Veterans’ Health Treatment

 

2.7A.1             The Commission may accept financial liability for CMVH treatment provided for the benefit of an entitled member who is entitled to such treatment under the Act.

 

Note (1): under subsection 13(1) of the Act treatment can be action taken with a view to maintaining a person in physical or mental health.

 

Note (2): the intention is that the Commission may accept liability for CMVH treatment even though such treatment is not provided by the Centre for Military and Veterans’ Health.

 

Note (3): prior approval for CMVH treatment is not required.

 

2.8       Loss of eligibility for treatment

2.8.1           The Commission will not accept financial responsibility for treatment provided to a person if that person is not, in the Commission's opinion, entitled to the treatment.

2.8.2           Where a person was entitled to treatment but is considered by the Commission to no longer be entitled to treatment or the person has received treatment for which, in the Commission's opinion, he or she was not entitled, the Commission or an employee of the Department must make a reasonable effort to notify the person that they are not entitled to treatment .

 


 

PART 3 — COMMISSION APPROVAL FOR TREATMENT

3.1       Approval for treatment

3.1.1       The Commission’s prior approval may be required for treatment.

 

3.2       Circumstances in which prior approval is required

3.2.1       Treatment requiring prior approval includes:

 

(a)        all medical specialist services in metropolitan areas;

Note:       see paragraph 4.7.1.
Prior approval
is not required in States or Territories where the MPPPs apply — see paragraph 1.2.2.

 

(b)            provision of services that are not made available under the Medicare Benefits Schedule.

 

Note:       see paragraph 4.2.3.

 

(d)            outpatient treatment at a private hospital where the requirement for prior approval for such treatment is specified in a contract;

 

(e)        treatment at a hospital according to the requirements contained in section 4 of the MPPPs;

 

            Note: where the patient is a holder of a White Card and eligibility for the treatment required is uncertain, the Commission will not accept financial responsibility for the cost of care unless the Department has verified eligibility.

 

(f)        admission to a hospital or the provision of hospital treatment not otherwise specified;

 

             Note:      see paragraph 9.1.8.

 

(h)            respite or convalescent admission to an institution;

 

Note:       see paragraph 9.6.1.

 

(j)         in-home respite care;

 

                   (ja)       emergency short term home relief (ESTHR) to be provided within 24 hours after a previous                                 service of ESTHR;

                               

                                Note: the intention is that 3 days (the max ESTHR per emergency) should                                                               be sufficient time for alternative respite care to be arranged and prior                                                                              approval is required before a further immediately subsequent service of                                                   ESTHR may be provided.

 

(k)        provision of residential care in Australia or overseas;

 

Note:       see paragraph 2.2.4 and Part 10.

 

(n)        dental treatment specified as requiring prior approval in Part 5;

 

(o)        community nursing services specified as requiring prior approval in Treatment Principle 7.3;

 

(p)        physiotherapy that exceeds the limits specified in paragraph 7.5.1;

 

(q)        podiatry that is not specified in paragraph 7.6.1;

 

(r)        provision of rehabilitation appliances;

 

Note:       see Part 11.

 

(s)        provision of visual aids not included under the arrangements entered into between the Commission and suppliers;

 

Note:       see paragraph 11.4.1.

 

(t)        repair of a rehabilitation appliance;

 

Note:       see paragraph 11.7.2.

 

(u)        chiropractic services that exceed the limits specified in paragraph 7.7.1;

 

(v)        osteopathic services that exceed the limits specified in paragraph 7.7.1; and

 

(w)       ambulance transport, except for that provided by certain ambulance services specified in paragraph 12.1.1;

 

(x)         cosmetic surgery;

 

(y)        medical devices not included on the Department's schedule of 'Benefits Payable in Respect of Surgically Implanted Prostheses, Human Tissue Items and Other Medical Devices;

 

(z)         psychiatric inpatient care or psychiatric day patient program care.

 

3.2.2       In considering whether prior approval will or will not be given and what conditions, if any, will apply, the following will be taken into account:

 

(a)        any specific requirements contained in these Principles or the Act;

 

(c)        the extent of funds that are available;

 

(d)        reasonable control over expenditure;

 

(e)        the clinical need for the proposed treatment; and

 

(f)         the suitability and quality of the proposed treatment.

 


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3.3       Circumstances in which prior approval is not required

3.3.2       Treatment not requiring prior approval includes:

 

(a)        treatment by Local Medical Officer or other GPs except where otherwise indicated in Part 4;

 

(b)       medical specialist consultations in country and Territory areas, except where otherwise indicated in principle 4.7;

Note:       Prior approval is not required for medical specialist consultations in States or Territories where the MPPPs apply — see paragraph 1.2.2.

 

(c)        dental treatment specified as not requiring prior approval in Part 5;

 

(d)        dental prosthetic treatment specified as not requiring prior approval in Part 5;

 

(e)        the prescription and supply of pharmaceutical items as set out in Part 6;

 

(f)         subject to paragraph 7.3.5, the provision of community nursing services by a nurse in accordance with paragraph 7.3.3 after the services have been provided;

 

                                Note: see principle 7.3.

 

                   (fa)       treatment under the MRCA Home Care Program          except a service of emergency short                                 term home relief (ESTHR) within 24 hours of a previous service of ESTHR;

                               

                                Note:see principle 7.3A.

                               

(g)       optometrical treatment and the dispensing of optical products under the arrangements between optometrists and optical dispensers and the Commission;

Note:       see principle 7.4.

 

(h)       physiotherapy treatment, except where otherwise indicated in principle 7.5.

 

(j)         podiatry treatment, except where otherwise indicated in principle 7.6;

 

(k)        treatment at a hospital under the conditions set out in paragraph 9.1.8;

 

(m)       ambulance transport in an emergency or where that is the arrangement between ambulance service providers and the Commission;

Note:       see paragraph 12.1.5.

 

(n)            referral to the Australian Hearing Service; and

 

(o)            chiropractic or osteopathic treatment, except where otherwise indicated in principle 7.7.

 

3.4       Other retrospective approval

3.4.1       On application, the Commission may approve, and pay the cost of, any treatment that was undertaken in the period between:

 

(a)        the effective date of eligibility under the Act; and

 

(b)        the date on which the person is notified of entitlement.

 

3.4.2       The Commission may provide approval for treatment that has already been given or has commenced to be given in circumstances where:

 

(a)        it would have accepted financial responsibility if prior approval had been sought before the service was provided; and

 

(b)        there are exceptional circumstances justifying the failure to seek prior approval;

 

or where:

 

(c)        a request for prior approval was incorrectly processed or failed to be processed due to an administrative error or processing error on the part of the Department or an officer of the Department.

 

3.4.3       The Commission will accept financial responsibility for emergency treatment for entitled persons and, subject to principle 2.2, for emergency treatment overseas for a service injury or service disease without prior approval only if approval is sought as soon as possible after the event.

 

Note:this Principle does not to apply to residential care or residential care (respite) provided overseas or in Australia.  In such cases the extent of Commission liability is determined under paragraphs 2.2.3 (c) and (d), and Part 10, of the Principles.

 

3.4.4       The Commission’s financial liability under paragraphs 3.4.1 and 3.4.3 is limited to the difference between:

 

(a)        the reasonable cost of treatment; and

 

(b)        the amount that an entitled person has claimed or is entitled to claim from Medicare, a health insurance fund or another third party.

 

3.4.5       The Commission’s financial liability under paragraph 3.4.2 is limited to the difference between:

 

(a)        the cost of treatment for which it is financially responsible under paragraph 3.5.1; and

 

(b)        the amount that an entitled person has claimed or is entitled to claim from Medicare, a health insurance fund or another third party.

 

3.4.6       The Commission will not pay or reimburse taxation levies for Medicare or for health insurance fund payments.

 

3.4.7       The Commission will accept financial responsibility under paragraphs 3.4.1, 3.4.2, and 3.4.3 if an application is supported by accounts, receipts, declarations or other evidence of the condition treated.

 

3.5       Financial responsibility

3.5.1       The extent of the financial liability accepted by the Commission for the provision of treatment for entitled persons is, subject to the Act and these Principles, as follows:

 

(a)        in respect of the fee charged by an LMO for a medical attendance or medical procedure, pursuant to the LMO's arrangement with the Commission ¾ an amount equal to 115% of the fee listed in the Medicare Benefits Schedule for that attendance or procedure, together with, for each attendance or procedure, a Veterans' Access Payment.

 

(aa)      in respect of the fee charged by an LMO for a medical attendance or medical procedure where:

                  

(i) the LMO is registered under the Rural Enhancement Scheme;and

 

(ii) the attendance or procedure is, respectively, provided or performed under the Rural Enhancement Scheme and pursuant to the LMO's arrangement with the Commission;

 

an amount equal to 125% of the fee listed in the Medicare Benefits Schedule for that attendance or procedure, together with, for each attendance or procedure, a Veterans' Access Payment.

 

(b)        in respect of the fees charged by an other GP:

 

(i)      for a medical attendance — an amount equal to the Medicare benefit for that attendance plus 60 cents per attendance; and

 

(ii)        for a medical procedure — an amount equal to the fee listed in the Medicare Benefits Schedule for that procedure;

 

(c)        in respect of the fee charged for a medical attendance, or medical procedure, by a Medical Specialist who is not an anaesthetist, a pathologist or a diagnostician — an amount equal to the fee listed in Schedule 2 (the MRCA Medical Fee Schedule) for that attendance or procedure.

 

(cc)      in respect of the fee charged for a medical procedure by a Medical Specialist who is a pathologist or diagnostician — an amount equal to the fee listed in the Medicare Benefits Schedule for that procedure.

 

(d)        in respect of the fee charged for a medical attendance or medical procedure by a Medical Specialist who is an anaesthetist:

 

(i)            an amount equal to the fee for that attendance or procedure listed in the Medicare Benefits Schedule;or

 

(ii)           if the anaesthetist has elected to be so paid, payment in accordance with the DVA time-based rates of pay for anaesthetists as determined by the Commission;

 

(e)        in respect of the fees payable to dental practitioners and dental prosthetists ¾ the financial liability that may be accepted by the Commission under Part 5 of the Principles;

 

(f)         in all other cases — in accordance with the fees payable under arrangements made by the Commission;

 

except where the Commission, having regard to the matters specified in paragraph 3.2.2, is satisfied that there are exceptional circumstances justifying payment of a higher fee.

 

 

 

 

3.5.2       The Commission will only accept financial responsibility for treatment:

 

(a)        that is reasonably necessary for the adequate treatment of the entitled person; 

 

(b)        that is given by an appropriate category of health provider; and

 

(c)             if a claim for payment in respect of treatment:

 

(i)                   is in the form, if any, approved by the Commission for this purpose ('approved form'); and

(ii)                 contains, or is accompanied by, any information required by any direction in any approved form; and

(iii)                is lodged at an appropriate place or with an appropriate person within the period of 6 months (or such longer period as is allowed in accordance with paragraph 3.5.2A) from the date of rendering the service to which the claim relates.

Note 1: a claim is taken to have been lodged on the day it is received.

Note 2: 'appropriate place' means an office of the Department in Australia or a place approved by the Commission for the purpose of lodging claims.

Note 3: 'appropriate person' means a person approved by the Commission for the purpose of lodging claims.

Note 4: a claim may be lodged by means of an electronic transmission.

 

3.5.2A                    Upon application in writing, by a claimant, to the Commission, the Commission may, in its discretion, by notice in writing served on the claimant, allow a longer period for lodging a claim than the period of 6 months referred to in subparagraph 3.5.2(c).

 

Note:'claimant' means an appropriate category of health provider seeking payment in respect of treatment provided under the Principles.

 

3.5.2B                    In exercising its power under paragraph 3.5.2A to allow a longer period for lodging a claim, the Commission shall have regard to all matters that it considers relevant, including, but without limiting the generality of the foregoing, any hardship that might be caused to the claimant if a longer period is not allowed.

Note: 'claimant' means an appropriate category of health provider seeking payment in respect of treatment provided under the Principles.

 

3.5.3                       The Commission will not accept financial responsibility for the cost of the following treatment by health providers, including treatment by dentists, physiotherapists and podiatrists:

 

(a)        services that have been paid for, wholly or partly, by Medicare or a health insurance fund; or

 

(b)        services where the cost is otherwise recoverable, wholly or partly, by way of a legal claim; or

 

(c)        examination for employment purposes; or

 

(d)        examination for a medical certificate for membership of a friendly society.

 

3.5.4          Where the Commission accepts financial responsibility under these MRCA Treatment Principles, it does so on behalf of the Commonwealth.

 


PART 4 — MEDICAL PRACTITIONER SERVICES

4.1    Medical Practitioner Services

 

4.1.2    Outline

 

4.1.3       The aim of the medical services program is to ensure that as far as practicable entitled persons have access to free, safe and cost-effective treatment.

 

To achieve this objective the Commission, or the Department on behalf of the Commission, deals with medical practitioners on four levels.

 

At the first level the Commission or the Department enters into agreements with general medical practitioners - these medical practitioners are called LMOs and are covered by these Principles. 

 

The second level of engagement is where the Commission or the Department deals with general medical practitioners who treat entitled persons otherwise than pursuant to a written agreement with the Commission or the Department but who charge rates set by these Principles - these medical practitioners are called other GPs and are covered by these Principles. 

 

The third level is where the Commission or the Department deals with general medical practitioners who treat entitled persons otherwise than pursuant to a written agreement with the Commission or the Department and who do not necessarily charge rates set by these Principles - these medical practitioners are not covered by these Principles but are covered by Part 2 of Chapter 6 of the Act.

 

The fourth level of interaction between the Commission or the Department and medical practitioners is where the medical practitioner is a specialist who treats entitled persons - these medical specialists do not (as at 1 January 2005) have written agreements with the Commission or the Department but are covered by these Principles if they are prepared to treat an entitled person at the rate set out in the Principles and charge the Commission, the Department or the Health Insurance Commission and not the entitled person.

 

It should be noted that while it is the Commission that accepts financial liability for treatment it is the Department (Commonwealth) that actually pays for the treatment.

 

                4.1.4       Subject to paragraph 3.5.1, the Commission may accept financial liability for medical treatment provided to an entitled person by an LMO, an other GP or a medical specialist.

 

Note: paragraph 3.5.1 sets out the financial limits on Commission liability for treatment.

4.2       Providers of services

4.2.1       Unless otherwise indicated in these Principles, an entitled person may be provided with only those services included in the Medicare Benefits Schedule.

 

 

 

4.2.2       The services referred to in paragraph 4.2.1 may be provided only by:

 

(a)        a Local Medical Officer or other GP; or

 

(b)        a medical specialist.

 

4.2.3 (1) An entitled person may be provided with services that are not made available under the Medicare Benefits Schedule ("unlisted services"). 

 

(2) Unlisted services are not to be provided to an entitled person if the Commission is satisfied that they             

are:

(a) a mere improvement on existing Medicare Benefits Schedule listed services; or

(b) experimental and have not been demonstrated to be effective or safe by extensive clinical trials.

 

4.2.4        Subject to paragraph 4.2.3(2), unlisted services are to be provided to an entitled person under paragraph 4.2.3(1) if the Commission is satisfied that the services will provide a substantial benefit to the health of the entitled person.

Note 1: the prior approval of the Commission is required before unlisted services may be provided (Paragraph 3.2.1 (b)).

Note 2: the availability of funds and the need to reasonably control expenditure are factors to be considered in granting prior approval (Subparagraphs 3.2.2 (c) and (d))

     

4.2.5        The services referred to in paragraph 4.2.3 may be provided only by:

 

(a)        a Local Medical Officer or other GP; or

 

(b)        a medical specialist.

 

4.3       Financial responsibility

4.3.1       Subject to paragraph 3.5.1, and unless otherwise indicated in these Principles, the Commission will accept financial responsibility for treatment costs where a Local Medical Officer or other GP or specialist provides or arranges for treatment of:

 

(a)            an entitled person who has been issued with a Gold Card ;or

 

(b)        an entitled person who has been issued with a White Card for any service injury or service disease; or

 

(c)        a person who has been issued with a written authorisation on behalf of the Commission;

 

4.3.2       In relation to any occasion of service to an entitled person under these Principles, a Local Medical Officer or other GP or specialist shall bill only:

 

(a) the Department; or

                   (b) the Commission; or

                   (c) the Health Insurance Commission,

 

and that bill shall be for full settlement of the account for the service provided to the entitled person.

 

4.3.3       Any billing method described in paragraph 4.3.2 may be used on each occasion of service.

 

4.3.4       Subject to paragraph 4.7.3, the Commission will accept financial responsibility for any of the services described in paragraph 4.4.1, irrespective of the billing arrangement chosen under paragraph 4.3.2 by the referring Local Medical Officer or other GP or specialist.

 


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4.4       Referrals

4.4.1       A Local Medical Officer or other GP may refer an entitled person for:

 

(a)        treatment from a medical specialist, subject to paragraph 4.7.1, and principles 4.5 to 4.8;or

 

(b)        treatment from a Local Medical Officer or other GP who has expertise or recognition in a particular field but is not a qualified medical specialist, subject to principles 4.5 to 4.8;or

 

(c)        treatment in a hospital or other institution as indicated in these Principles; or

 

(d)        other health-care services not requiring prior approval, as indicated in principles 7.3, 7.5 and 7.6.

 

4.5       Referrals by medical specialists

4.5.1       In providing treatment, a medical specialist, to whom an entitled person is referred under these Principles, may:

 

(a)        arrange diagnostic tests;or

 

(b)        refer the entitled person to another specialist in the same way as may a Local Medical Officer or other GP;or

 

(c)        arrange treatment in a hospital or other institution as indicated in these Principles; or

 

(d)        refer the entitled person to a health-care provider in accordance with principles 7.3, 7.5 or 7.6, in the same way as may a Local Medical Officer or other GP.

 

4.6       Referrals to medical specialists in country or Territory areas

4.6.1       Subject to principles 4.7 and 4.8, the Commission will accept, without the need for prior approval, financial responsibility for treatment of entitled persons upon referral to medical specialists in a country or Territory area, provided that the entitled persons are referred by Local Medical Officer or other GPs to medical specialists in the local area.

Note:       Prior approval is not required in States or Territories where the MPPPs apply — see paragraph 1.2.2.

 

4.6.2       Referrals under paragraph 4.6.1 shall be valid from the date of the specialist’s or consultant physician’s first service.

 

4.7       Referrals: prior approval

4.7.1       In all instances other than those described in principle 4.6 and paragraph 4.7.3, prior approval is required for the referral of entitled persons to medical specialists.

 

4.7.2       Prior approval is required for:

 

(a)        the provision of treatment for pregnancy and pregnancy related conditions;or

 

(b)        the provision of psychotherapy treatment to entitled persons; or

 

(c)        the provision of services under paragraph 4.2.3.

 

4.7.3       Prior approval is not required when a Local Medical Officer or other GP or medical specialist refers an entitled person for radiology or pathology services not requiring admission:

 

(a)        if the provider direct bills at 85 per cent or less of the fee set out in the Medicare Benefits Schedule as full settlement of the account for the services rendered; or

 

(b)        if the Commission so determines.

Note:       Prior approval is not required in States or Territories where the MPPPs apply — see paragraph 1.2.2.

 

4.8       Other matters

4.8.1       The Commission will not accept financial responsibility for the cost of:

 

(a)        elective surgery undertaken without prior approval with the exception of minor procedures carried out in a Local Medical Officer or other GP’s or specialist’s rooms where the only charge is equivalent to the charge that would be applicable under the Medicare Benefits Schedule for that procedure; or

Note:      Prior approval is not required for elective surgery undertaken in public hospitals in States or Territories where the MPPPs apply — see paragraph 1.2.2.

 

(b)        examination for a medical certificate for life assurance purposes; or

 

(c)        examination for a medical certificate for membership of a friendly society; or

 

(d)        examination for employment purposes; or

 

(e)        multi-phasic screening; or

 

(f)         services where the cost is otherwise recoverable wholly or partly, by way of a legal claim; or

 

(g)        services that have been paid for, wholly or partly, by Medicare or a health insurance fund; or

 

(h)        treatment for infertility for the partner of an entitled person, unless that partner is personally eligible for treatment for the disability under the Act; or

 

(j)         procedures associated with in-vitro fertilisation programs; or

 

(k)        vaccination or inoculation in connection with overseas travel.


 

PART 5 — DENTAL TREATMENT

5.1       Providers of services

5.1.1       The Commission may prepare a Local Dental Officer Scheme, not inconsistent with these Principles, concerning the provision of dental treatment to entitled persons by private dental practitioners under arrangements entered into with the Commission.

 

5.1.2       Compliance with the Local Dental Officer Scheme, as in force at 1 June 1993, is a condition of the contract for services with each Local Dental Officer.

 

5.1.3       Dental prosthetic services may be provided to entitled persons by dental prosthetists under arrangements entered into with the Commission.

 

5.1.4       Subject to prior approval and these Principles, the Commission will accept financial responsibility for dental treatment provided in a hospital.

 

5.1.5       Subject to prior approval, an entitled person may be referred to a dental specialist by a Local Dental Officer, dental prosthetist or a dental specialist.

 

5.2       Financial responsibility

5.2.1       The Commission may prepare Dental Schedules A, B and C and a Dental Prosthetist Schedule that list dental services provided or arranged by the Commission and the limits of financial responsibility accepted by the Commission.

Note:       Copies of the Local Dental Officer and Dental Prosthetists Fees Bulletins that contain details of these Schedules may be obtained from any office of the Department.

 

5.2.2       The Commission may set a monetary limit that will apply to entitled persons for services provided under Dental Schedule C for a calendar year.

 

5.2.3       The Commission will not accept financial responsibility for dental services provided to an entitled person under Dental Schedule C that exceed, in total, the annual monetary limit for that person as set under paragraph 5.2.2.

 

5.2.4       Until the annual limit has been exceeded, the Commission will pay up to the Schedule fee for each item.

 

5.2.5       The annual monetary limit set under paragraph 5.2.2 will not apply in relation to a dental service where that service is for a service injury or service disease.

 

5.2.6       Subject to paragraph 5.5.1, the Commission will not accept financial responsibility for dental treatment after a person is no longer entitled to the treatment.

 

5.3       Entitlement

5.3.1       Subject to these Principles, an entitled person who holds a Gold Card, White Card or written authorisation issued on behalf of the Commission, may be provided with dental services at the expense of the Commission.

 

5.3.2       A person who holds a Gold Card will be provided with the following dental services:

 

(a)        for treatment of an injury or disease that is not service injury or disease:

 

(i)         without prior approval — those dental services listed in Schedule A, except where specified;

 

(ii)        with prior approval — those dental services listed in Schedule B; and

 

(iii)       without prior approval and subject to paragraph 5.2.2 — those dental services listed in Schedule C;

 

(b)        for treatment of a service injury or service disease:

 

(i)         without prior approval — those dental services listed in Schedule A, except where specified;

 

(ii)        with prior approval — those dental services listed in Schedules B and C, but without the limit referred to in paragraph 5.2.2.

 

5.3.4       Persons who hold a “White Card" are entitled to dental treatment of a service injury or a service disease and, subject to prior approval, may be provided with any dental services listed in the Schedules.

 

5.4       Emergency dental treatment

5.4.1       Prior approval is not necessary for emergency dental treatment but the Commission will not accept financial liability for the treatment if approval has not been obtained as soon as possible after treatment. 

 

5.4.2       Financial responsibility for emergency dental treatment for persons who hold a “White Card " will only be accepted for treatment of a service injury or service disease.

 

5.5       Orthodontic treatment for children

5.5.1       Orthodontic treatment will continue to be provided for an eligible young person of a deceased member if the eligible young person has ceased to be eligible for treatment because he or she has turned sixteen years of age or has ceased full-time education if:

 

(a)        the treatment is approved by the Commission while the eligible young person is still eligible; and

 

(b)        the treatment is commenced while the eligible young person is still eligible; and

 

(c)        the treatment will be completed within two years of commencement of treatment or such longer time as the Commission considers reasonable.

 

5.6       General anaesthesia

5.6.1       Financial responsibility for a general anaesthetic provided as part of dental treatment will be accepted only if:

 

(a)        the anaesthetic is administered by a specialist anaesthetist or approved medical practitioner in a hospital or dental surgery where adequate resuscitation equipment is provided; and

 

(b)        prior approval has been obtained.

 

5.7       Prescribing of pharmaceutical benefits by dentists

5.7.1       Local Dental Officers or dental specialists may prescribe Pharmaceutical Benefits for entitled persons.

 

5.7.2       Subject to paragraph 5.7.4, prescriptions prescribed under paragraph 5.7.1 must be in accordance with the PBS.

 

5.7.3       The Commission will accept financial responsibility for Pharmaceutical Benefits, available under the PBS that are required as part of dental treatment:

 

(a)        for a service injury or service disease of an entitled person who holds a “White Card "; or

 

(b)        for an entitled person who holds a“Gold Card ";

 

other than the amount that would have been payable by the person if the person were a “concessional beneficiary” under the National Health Act 1953.

 

5.7.4       The Commission will accept financial responsibility for Pharmaceutical Benefits that are not available under the PBS and are required as part of dental treatment:

 

(a)        for a service injury or service disease of a person who hold a“White Card "; or

 

(b)        for a person who holds a“Gold Card ";

 

but such a prescription must be written on a private prescription.

 

5.8       Other dental services

5.8.1       The Commission will not accept financial responsibility for dental treatment that involves the use of intravenous sedation or relative analgesia technique in a Local Dental Officer’s or dental specialist’s surgery.

 


 

PART 6 — PHARMACEUTICAL BENEFITS

6.1       MRCA Pharmaceutical Benefits Scheme

6.1.1       The MRCA Pharmaceutical Benefits Scheme (prepared by the Commission under paragraph 286(1)(c) of the Act) relates to the supply of Pharmaceutical Benefits to entitled persons by community pharmacists as defined in that Scheme.

 

6.2       Entitlement under the MRCA Pharmaceutical Benefits Scheme

6.2.1       A person is eligible to receive Pharmaceutical Benefits under the MRCA Pharmaceutical Benefits Scheme if that person holds:

 

(a)        a “White Card" " for a service injury or service disease; or

(b)        a Gold Card.

 

 


 

PART 7 — TREATMENT GENERALLY FROM OTHER HEALTH PROVIDERS

7.1       Prior approval and financial responsibility for health services

7.1.1        Subject to the exceptions set out in paragraphs 3.3.2, 7.3 to 7.6 and 7.3A.13 the Commission will accept financial responsibility for treatment services provided by a health provider only if the Commission has given prior approval for those services to be provided.

 

7.1.1A    In relation to any occasion of service to an entitled person under these Principles, except an occasion of service that is a service under the MRCA Home Care Program, a health provider shall bill only the Department and that bill shall be for full settlement of the account for the service provided to the entitled person but in relation to any occasion of service to an entitled person under these Principles that is the provision of a service under the MRCA Home Care Program, a health provider shall bill the Department but not for any co-payment payable by an entitled person to the health provider and the bill presented to the Department shall be for full settlement of the account for the service provided to the entitled person.

 

7.1.2       Subject to these Principles and in addition to services provided under principle 2.6 and paragraph 5.1.3, the Commission may provide, arrange, or accept financial responsibility for the following:

 

(a)        audiology

 

(b)        dietetics;

 

(c)        chiropractic services;

 

(d)        community nursing;

 

(e)        occupational therapy;

 

(f)         optometry;

 

(g)        orthoptics;

 

(h)        osteopathic services;

 

(i)              Home Care service (category A); Home Care service (category B);

 

(j)         physiotherapy;

Note:       Physiotherapy includes hydrotherapy (see paragraph 1.4.1)

 

(k)        podiatry;

 

(l)         psychology;

 

(m)       social work;

 

(n)        speech pathology.

 

7.1.3       The Commission will not accept financial responsibility for services listed in paragraph 7.1.2 for an entitled person receiving a high level of residential care where the provision of those services is covered by a State or Commonwealth subsidy.

 

7.1.4        Treatment in an entitled person’s home may be approved where the entitled person is medically unable to attend the relevant facilities or where the entitled person is entitled to treatment at home under the MRCA Home Care Program.

.

7.2       Registration or enrolment of providers

7.2.1       Where a provider of a service specified in principle 7.1 (other than a service of community nursing) is practising in a State or Territory that has legislation requiring the registration of the occupation, the provider must be registered under that legislation.

 

Note: the occupational registration of community nursing providers is dealt with in the arrangements between the Commission and community nursing providers.

 

7.2.2       Where a State or Territory does not have legislation concerning registration, a provider of a service specified in principle 7.1 (other than a service of community nursing) must be registered in another State or possess qualifications that would permit registration in another State or must be registered in another Territory or possess qualifications that would permit registration in another Territory, if that other State or other Territory has legislation requiring the registration of the occupation in question

 

Note: the occupational registration of community nursing providers is dealt with in the arrangements between the Commission and community nursing providers.

 

7.2.3          Where the provider of a service specified in principle 7.1 (other than a service of community nursing) is a corporate entity and is practising in a State or Territory that has legislation enabling registration of the corporate entity, both the person actually delivering the service and the corporate entity must be registered under the relevant legislation.

 

Note: the occupational registration of community nursing providers is dealt with in the arrangements between the Commission and community nursing providers.

 

7.3       Community nursing

7.3.3       The Commission will accept financial responsibility for community nursing services for an entitled person only if:

 

(a)           the person has been referred to a community nursing provider by a Local Medical Officer or other GP, treating doctor in a hospital, hospital discharge planner or MHC assessment agency; and

 

Note: paragraph 7.3.6 sets out the community nursing providers to whom an entitled person can be referred under paragraph 7.3.3(a).

 

(b)           a community nursing provider, pursuant to an arrangement with the Commission, has undertaken a nursing assessment of the entitled person prior to the commencement of care and assessed that the person has a clinical need or a personal care need, or both, for the community nursing service.

 

7.3.4       All of an entitled person’s care documentation prepared by a community nursing provider shall be provided to the Department upon request by the Department to the community nursing provider.

 

7.3.5       An entitled person whose care needs, due to their complexity and care regime, are significantly outside of the scope of the community nursing classification to which they belong, is treated under the exceptional case process.  Before a person can be treated under the exceptional case process, prior approval must be obtained from the Commission.

 

7.3.6  A referral to a community nursing provider is to be made only to a community nursing provider that has entered into, and is bound by, a contract with the Commission or the Department to provide community nursing services during the relevant period of treatment and in the geographical area in which the entitled person resides.

 

7.3.6A If no community nursing provider referred to in paragraph 7.3.6 can provide the relevant community nursing care within a reasonable time, the Commission may approve a referral to another community nursing provider.

 

7.3.7       The Commission will not accept, as part of a community nursing service, financial responsibility for any domestic help services such as cooking, shopping, cleaning, laundry, transport and companionship.

 

7.3A            MRCA Home Care Program

7.3A.1 (1)    The Commission may examine the circumstances of an entitled person and assess whether the person is in need of a Home Care service (category A) or a Home Care service (category B).

 

(2) The Commission may determine that an assessment made under paragraph (1) is to be effective from a date before or after the date on which the assessment is made.

 

(3) The Commission shall ensure a record is made of any assessment under paragraph (1) and any determination under paragraph (2).

 

(4) A record under paragraph (3) may be made and maintained in electronic form.

 

7.3A.3 (1)              An entitled person is not entitled to a service of Home and Garden Maintenance if the provision of the service would mean the person had received Home and Garden Maintenance for a period or periods that would exceed, or cumulatively exceed, 15 hours over the relevant period.

 

(2)               For the purposes of paragraph 7.3A.3 (1), the relevant period is a period of 12 months commencing on the date when the Commission accepted financial liability for the provision of Home and Garden Maintenance to the entitled person, or on the anniversary of that date.

 

Note: the intention is that unused hours of Home and Garden Maintenance in a 12 month period are not carried over into the next 12 month period.

 

7.3A.4 (1) Where under paragraph 7.3A.1 (1) the Commission decides that an entitled person is not in need of a relevant service, it shall inform the entitled person accordingly and give reasons for its decision.

 

             (2) Where under paragraph 7.3A.1 (1) the Commission decides that an entitled person is in need of a relevant service, then, in the case of a Home Care service (category A), it shall arrange for an appropriate approved provider to supply that service, and, in the case of a Home Care service (category B), the Commission shall supply that service.

 

Note:in practice the Commission may delegate its powers to assess "Home Care need" and to arrange for the supply of a Home Care service (category A), to contractors and may delegate its power to supply a Home Care service (category B) to a contractor.  Those contractors may, in turn, sub-contract the obligation to supply the relevant services.

               

7.3A.5    The Commission may accept financial responsibility for the provision of a Home Care service (category A) to an entitled person by an approved provider if the service is supplied:

 

                (i) in accordance with the arrangement between the approved provider and the Commission; and

                (ii) in accordance with the terms of a decision under paragraph 7.3A.1(1) that the entitled person

                      needed the service; and

                (iii) in accordance with the Principles.

 

7.3A.6                    The Commission may accept financial responsibility for the provision of a Home Care service (category B) to an entitled person by the Commission.

 

Note: in practice the Commission may delegate its power to assess "Home Care need" to a contractor and may delegate its power to supply a Home Care service (category B) to a contractor.  Those contractors may, in turn, sub-contract the obligation to supply the relevant services.

 

7.3A.7    For the purposes of the Principles, an approved provider is deemed to be a health provider.

 

7.3A.8                    Subject to paragraph 7.3A.9, a condition of any arrangement between the Commission and an approved provider for the provision of a Home Care service (category A) to an entitled person by the approved provider or any sub-contractor engaged by it, is that:

 

(a)        the approved provider, and any such sub-contractor, shall not demand, receive or assign, an amount from the entitled person in relation to the provision of the Home Care service (category A) that exceeds $5 per hour of service; and

 

(b)       the approved provider, and any such sub-contractor, shall not demand, receive or assign a proscribed amount from the entitled person in relation to the provision of the Home Care service (category A).

                        

7.3A.9    For the purposes of paragraph 7.3A.8, in relation to a proscribed amount that is an exempt amount, it is only a condition of an arrangement not to demand, receive or assign such a proscribed amount if the Commission has made a determination under paragraph 7.3A.10 and notified the approved provider, whether by electronic means or otherwise, of the effect of that determination.

 

7.3A.10 Pursuant to a request in writing from an entitled person or an approved provider, the Commission shall determine whether, in the opinion of the Commission, an entitled person is or is not an exempt entitled person and such a determination shall be recorded in writing and shall be prima facie evidence of the matters contained therein.

 

Note: an exempt entitled person is not required to pay an amount the person would otherwise be required to pay to an approved provider in respect of a Home Care service (category A).

 

7.3A.11 Where:

 

             (a)  under paragraph 7.3A.8, an entitled person cannot be required to pay an amount of money in respect of a Home Care service (category A) provided or to be provided to that person by an approved provider or a sub-contractor, because:

 

                         (i)      the person is an exempt entitled person; or

                         (ii)     the Home Care service (category A) provided or to be provided to the entitled person is a            

                                   similar service to a Home and Community Care Program service the entitled person received immediately before 1 January 2001 and in respect of which the entitled person had not been required to pay a charge ("similar service no charge"); or

                         (iii)    the Home Care service (category A) provided or to be provided to the entitled person is a           

                                   similar service to a Home and Community Care Program service the entitled person

                                   received immediately before 1 January 2001 and in respect of which the

                                   entitled person had been required to pay a charge ("similar service some charge") but the

                                   amount of money that could have been required of the person under the MRCA Home

                                   Care Program, but for it being a proscribed amount, exceeds that charge; and

                                  

             (b) a Home Care service (category A) is provided to the entitled person by an approved provider or a sub-contractor;

 

                the Commission will accept responsibility to pay to the approved provider in respect of the Home Care service (category A):

 

                (c)     in the case where the entitled person could not be required to pay an amount because the person was an exempt entitled person — an amount equal to the amount the person could have been required to pay if the person had been an entitled person who was not an exempt entitled person;

 

                (d)     in the case where the entitled person could not be required to pay an amount because the person

was provided with a "similar service no charge" — an amount equal to the amount the person could have been required to pay if the Home Care service (category A provided to the entitled person had not been a "similar service no charge";

 

                (e)     in the case where the entitled person could not be required to pay a certain amount because the            

                         person was provided with a "similar service some charge" and the amount the person could not           

                         be required to pay was a proscribed amount because it exceeded the amount the person was

                         charged when the person received the Home and Community Care Program service on which the

                         "similar service some charge" was based — an amount equal to that proscribed amount;

                        

                         Note: it is the intention that the Commission accept responsibility for a proscribed amount

                         referred to in paragraph (f) of the definition of "proscribed amount" (part of charge per hour) and

                         not for the proscribed amount referred to in paragraph (b) of the definition of "proscribed amount"

                         (amount exceeding maximum amount payable weekly or over a longer period).

                        

                         7.3A.12        A condition of any arrangement between the Commission and an approved provider for the provision of a Home Care service (category A) to an entitled person by the approved provider or any sub-contractor engaged by it, is that a Home Care service (category A) will not be provided to an entitled person receiving residential care under the Aged Care Act 1997 including where the Commission accepts financial responsibility for the provision of that residential care pursuant to the Principles.

 

7.3A.13 The prior approval of the Commission for the provision of a Home Care service (category A) to an entitled person by an approved provider or for the provision of a Home Care service (category B) to an entitled person by an approved provider is not required except that in the case of the provision of a Home Care service (category A) to an entitled person by an approved provider that is emergency short term home relief (ESTHR), the prior approval of the Commission is required for the provision of ESTHR within 24 hours after a previous service of ESTHR.

 

Note: the fact that the Commission's prior approval for treatment is not required does not mean an assessment is not required.

 

Transitional

 

7.3A.14  For the purposes of paragraph 7.3A.15:

                                              

"former service", in relation to an entitled person, means any Home and Community Care Program service the person was receiving immediately before 1 January 2001 or after 1 January 2001 and immediately before the person seeks services under the MRCA Home Care Program.

                                              

7.3A.15 (1)           An entitled person who was receiving a former service is entitled to receive whichever of Home Care service (category A) services or of Home Care service (category B) services is the most similar to that former service if the Commission assesses the person as needing one of those services.

 

(2)           Upon the Commission deciding a person in paragraph (1) is entitled to a Home Care service (category A) or a Home Care service (category B), then the entitlement of that person to the service is subject to the Principles.

 

7.3A.16        Where a decision is made under paragraph 7.3A.15 (1), including a decision not to provide a service, the Commission shall make a record of the decision and give notice of the decision to the entitled person.

 

Note: a decision may be recorded in electronic form and notice of the decision may be given in electronic form.

                                               

7.3A.17        Upon the Commission making a decision under paragraph 7.3A.15 (1), the entitled person's entitlement, if any, to a Home Care service (category A), or to a Home Care service (category B), has effect subject to that decision.

 

Limited MHC-type services for dependants and former dependants

                                               

7.3A.19A               Definitions

 

For the purposes of paragraphs 7.3A.19A to 7.3A.22 (inclusive):

 

eligible person means a person who is eligible for a service.

service means a limited MHC-type service.

 

7.3A.19        Subject to paragraph 7.3A.21, the Commission may accept financial responsibility for the provision of a limited MHC-type service to a person eligible to receive the service.

                                              

7.3A.20        A person eligible for a limited MHC-type service is a person who the Commission decides is:

 

(a) a former partner who was a dependant of a deceased entitled member ¾ in circumstances where the deceased entitled member was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both; or

 

             (b) an eligible young person who was a dependant of a deceased entitled member ¾ in circumstances where the deceased entitled member was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both; or

 

(c)  a former eligible young person who was a dependant of a deceased entitled member ¾ in circumstances where the deceased entitled member was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both and the former eligible young person is a person with a serious disability; or

 

(d) a former eligible young person who was a dependant of a deceased entitled member ¾ in circumstances where the deceased entitled member was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both and the former eligible young person was a full-time carer of the deceased entitled member immediately prior to the death of the entitled member; or

 

(e)  the partner of an entitled member ¾ who resided with that member immediately before the member needed to leave the home in order to receive treatment, and at or about the time of the member's departure the member was being provided with Domestic Assistance or Home and Garden Maintenance or both; or

 

(f) either: (i) an eligible young person who is a dependant of an entitled member; or

                              (ii) a former eligible young person who is a dependant of an entitled member;

 

who resided with the entitled member immediately before the entitled member needed to leave the home in order to receive treatment and at or about the time of the departure of the entitled member:

 

(iii) the entitled member was being provided with Domestic Assistance or Home and Garden Maintenance or both; and

               (iv) in the case of a former eligible young person who is a dependant of an entitled member and who is residing with the member ¾ the former eligible young person is a person with a serious disability or was the full-time carer of the entitled member.

 

7.3A.21                  The conditions on which the Commission will accept financial responsibility for the provision of a limited MHC-type service to a person eligible to receive the service are:

 

(1) in respect of an eligible person in paragraph 7.3A.20 (a) — the service is provided for a period of no longer than 12 weeks commencing on the day after the day on which the entitled member died ("commencement day"), unless, within the period of 12 weeks commencing on the commencement day, the person makes a claim for compensation under section 319 of the Act in which case the service is provided for no longer than the period commencing on the commencement day and ending at the end of the day on which the Commission determines the claim.

 

Note (1): in practice a Commission delegate will determine a claim and the Department will communicate details of the determination to the delegate of the Commission who arranged provision of the limited MHC-type service.

 

Note (2): in practice the Commission will be a delegate exercising the Commission's assessment powers.

 

(2) in respect of an eligible person in paragraphs 7.3A.20 (e) or (f), the service is provided over a period no longer than 12 consecutive weeks commencing on the day the entitled member left the home for treatment.

 

(3) the service is identical to either Domestic Assistance or Home and Garden Maintenance (or both) that the relevant entitled member was receiving at or about the time of his or her death or at or about the time of his or her departure from the home for treatment, as the case may be.

 

(4) the service is provided on the same terms, including any liability to make a co payment, that the Domestic Assistance or Home and Garden Maintenance (or both) was provided to the relevant entitled member at or about the time of his or her death or at or about the time of his or her departure from the home for treatment, as the case may be.

 

(5) the eligible person resided in the home of the relevant entitled member at the time of the death of the relevant entitled member or at the time the relevant entitled member departed from the home for treatment, as the case may be.

 

(6) in order for an eligible person referred to in paragraph 7.3A.20 (d) to be provided with a service, the eligible person must have been the full-time carer of the entitled member immediately prior to the death of the member at or about the time the service is required.

 

7.3A.22                  For the purposes of paragraph 7.3A.21, a particular entitled member is a "relevant entitled member" in relation to a particular eligible person, where the eligible person was residing with that member at the time of the death of the member or at the time of the departure of the member from the home for treatment, and the eligible person is relying on that fact as constituting an element necessary to establish the basis for the person's entitlement to a service.

                                           

Note (1): the intention is to ensure that the conditions for providing a service to an eligible person are related to that person's particular circumstances.  For example, a former eligible young person who resided with an entitled member before his/her death is only entitled to the domestic-type assistance that member was receiving and is not entitled to the domestic-type assistance some other entitled member was receiving. 

 

Similarly, a former eligible young person is not entitled to Home and Garden-type maintenance if the relevant entitled member had not been receiving Home and Garden Maintenance.  The entitlement of the eligible person is to reflect the entitlement of the primary beneficiary ie the

entitled member.

                                           

7.4       Optometrical services

7.4.1       The Commission will accept financial responsibility for optometrical services provided to an entitled person who consults an optometrist participating in the arrangements between optometrists and the Commission.

 

7.4.2       The Commission may, from time to time, prepare a Schedule of Prescribable Items that lists the products that may be supplied under these Principles by participating optometrists and other optical dispensers.

Note:       The Schedule of Prescribable Items is available at any office of the Department.

 

7.4.3       A participating optometrist may render the account for services provided to an entitled person either to the Department or to Medicare under the direct billing arrangements.

 

7.4.4       When a participating optometrist direct bills Medicare and visual aids are prescribed, these may be provided under paragraph 7.4.2.

 

7.5       Physiotherapy

7.5.1       The Commission will accept, subject to paragraph 7.5.3, financial responsibility for physiotherapy treatment for a period, where an LMO or medical practitioner refers an entitled person to a registered physiotherapist to whom the Health Insurance Commission has given a provider number.

 

Note:       Physiotherapy includes hydrotherapy (see paragraph 1.4.1).

 

7.5.2       The period referred to in paragraph 7.5.1 commences on the date of the Local Medical Officer or other GP’s, or medical specialist’s, referral.

 

7.5.3       Prior approval is required for physiotherapy treatment:

 

(a)           where those services are to be provided to an entitled person classified as a high care patient in a residential aged care facility;

 

                (b)           where those services are to be provided in a public hospital; or

 

                (c)           involving lymphoedema treatment.

 

7.5.4       The Commission may accept financial responsibility for hydrotherapy treatment that does not include recreational water exercises or recreational swimming.

 

7.6                 Podiatry

7.6.1       Subject to paragraph 7.6.6, the Commission will accept financial responsibility for podiatry treatment where a Local Medical Officer or other GP or medical specialist refers an entitled person to a registered podiatrist (to whom the Health Insurance Commission has given a provider number), for an episode of care.

 

7.6.2       Prior approval is required for podiatry treatment:

 

(a)                 where those services are to be provided to entitled persons classified as high care patients in a residential aged care facility;

 

(b)                 where those services are to be provided in a public hospital;

 

(c)                 when prescribing temporary footwear, prescribing more than two pairs of medical grade footwear;

 

(d)                 prescribing more than three pairs for entitled persons living in remote areas;

 

(e)                  repairing depth and custom footwear if the cost is over $100;

 

(f)                   modifying depth and custom footwear if the cost is over $100;

 

(g)                 providing an Electrodynographic Analysis and Report;

 

(h)                 providing a Video Gait Analysis and/or Treadmill Analysis and Report;

 

(i)                   delivering services valued at over $60 under the Miscellaneous Items listed in the Deed of Agreement between the Commission and the podiatrist.

 

7.6.3       The Commission will accept financial responsibility for surgical removal of the toenail plate (either partial or total) by a registered podiatrist (to whom the Health Insurance Commission has given a provider number), with or without sterilisation of the matrix, only if prior approval has been obtained.

 

7.6.4               The Commission may use an approved contracted supplier for the provision of

footwear.

 

7.6.5       The Commission will accept financial responsibility for footwear, and footwear repairs, only if the footwear is:

 

                (a)           medical grade footwear;

 

(b)           prescribed by a registered podiatrist, or a medical specialist who is a

                rehabilitation specialist, orthopaedic surgeon or rheumatologist; and

 

(c)           supplied by an approved contractor or other supplier approved by the

                Commission.

 

7.6.6       Except where the Commission decides otherwise, financial responsibility will not be accepted for routine toenail cutting.

 

 

 

 


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7.7                 Chiropractic and osteopathic services

 

7.7.1           The Commission will accept financial responsibility for chiropractic or osteopathic services where a Local Medical Officer or other GP or medical specialist refers an entitled person to a registered chiropractor or osteopath to whom the Health Insurance Commission has given a provider number.

 

7.7.2          The Commission will only accept financial responsibility for chiropractic and osteopathic services involving treatment of the musculo-skeletal system. No other treatment will be accepted.

 

7.7.3          The Commission will only accept financial responsibility for x-rays taken by a registered chiropractor who is licensed to take x-rays under relevant State or Territory legislation.

 

7.7.5               The Commission will not accept financial responsibility for the provision of

concurrent courses of physiotherapy and chiropractic services or physiotherapy and osteopathic services for the same condition to any entitled person.

 

7.8       Other services

 

7.8.1       The Commission will not accept financial responsibility for certain services, including:

 

(a)        herbalist services;

 

(b)        homeopathy;

 

(c)        iridology;

 

(d)        massage that is not performed as part of authorised physiotherapy, chiropractic or osteopathy services; and

 

(e)        naturopathy.

 

 

 


PART 9 — TREATMENT OF ENTITLED PERSONS AT HOSPITALS AND INSTITUTIONS

9.1       Admission to a hospital or institution

9.1.1       Subject to these Principles, the Commission will accept financial responsibility for the provision of treatment to entitled persons at a hospital or an institution.

 

9.1.2       The Commission will not approve, or accept financial responsibility for, admission to a hospital or an institution if:

 

(b)        the person could have been provided with suitable outpatient treatment; or

 

(c)        the person could have been suitably cared for at home, with or without supporting community health care services, unless the admission would provide respite for a carer of an entitled person.

 

9.1.3       Notwithstanding other provisions of these Principles, the Commission will accept financial responsibility for the emergency admission to the nearest hospital of an entitled person for treatment if an office of the Department is notified on the first working day after the admission, or as soon thereafter as is reasonably practicable if that admission is to a private hospital requiring prior approval as set out in Part 3 of these Principles.

 

9.1.4       Where hospital treatment of an entitled person has been arranged under these Principles, and the person’s partner is an inpatient at another hospital within reasonable proximity, the Commission may arrange the admission or transfer of the person to the hospital at which the person’s partner is an inpatient.

 

9.1.5       If such arrangements are made under paragraph 9.1.4, the Commission will accept financial responsibility for the hospital treatment of the entitled person.

 

9.1.6       The Commission will accept financial responsibility for the admission of an entitled person to a Tier 2 or Tier 3 hospital, as set out in Principle 2 of the MPPPs, only if prior approval for the admission is obtained.

 

9.1.7       When giving consideration of prior approval under paragraph 9.1.6, the Commission will have regard to the matters set out in paragraph 3.2.2 and in Principle 2 of the MPPPs.

 

9.1.8       Subject to this Part, the Commission will accept financial responsibility for inpatient treatment of an entitled person in a country or a Territory public hospital or in a private hospital with which arrangements have been previously agreed with the Commission and according to the preferences and requirements set out in Part 3 of these Principles and in Principle 2 of the RPPPs.

 

9.1.9       The Commission’s approval is required before it will accept financial responsibility for the admission to hospital, or for hospital treatment, of entitled persons in all other circumstances.

 

9.1.10     Where prior approval is required, the Commission will not accept financial responsibility for any additional charges where an admission for treatment is arranged according to these Principles and then non-Medicare Benefits Schedule surgery or cosmetic surgery is performed subsequently without the Commission's approval.

 

 

 

9.2       Financial Responsibility For Treatment In Hospital

9.2.1       Subject to paragraph 9.2.5, the Commission will accept financial responsibility for any usual and reasonable hospital treatment that takes place at the hospital for persons admitted in accordance with these Principles.

 

9.2.2       The Commission may accept financial responsibility for any usual and reasonable treatment that takes place outside the hospital if it is prescribed as a necessary part of inpatient treatment.

 


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9.2.4       Subject to paragraph 9.2.5, the Commission will accept financial responsibility for hospital charges on the basis of:

 

(a)        for a public hospital — an amount in accordance with arrangements made with the appropriate State/Territory authority; or

 

(b)        for a contracted private hospital — the rate agreed between the Commission and the hospital;or

 

(c)        for a non-contracted private hospital, when neither a public nor a contracted private hospital can provide the treatment required — the rate agreed from time to time between the Commission and the hospital; or

 

(d)        for a non-contracted hospital, when chosen by an entitled person in preference to a contracted private hospital — a rate to be determined by the Commission.

 

9.2.5       The Commission will not accept financial responsibility for the whole, or that portion, of:

(a)        hospital charges; or

 

(b)        charges for any surgically implanted prostheses; or

 

(c)        charges paid by health fund benefits,

 

in circumstances where the entitled person:

 

(d)        is insured by private health insurance for hospital charges or surgically implanted prostheses; and

 

(e)        agrees to assign to the hospital or other institution the benefits available from private health insurance in respect of all or part of the hospital charges or surgically implanted prostheses.

 

9.3       Nursing-home-type care

9.3.1       Where:

 

(a)        an entitled person remains an inpatient in excess of 35 consecutive days and there is no acute care certificate under section 3B of the Health Insurance Act 1973 in force stating reasons approved by the Commission for the continuing need for acute care; or

 

(b)        the medical practitioner responsible for treating the entitled person agrees at any time after admission that the entitled person no longer requires acute care;

 

the person will be regarded as receiving nursing-home-type care.

 

9.3.2       If an entitled person:

 

(a)           is eligible for a residential care subsidy under the Aged Care Act 1997; and

                (b)           is receiving nursing-home-type care as defined in paragraph 9.3.1;

 

the Commission will accept financial responsibility for the standard hospital fee for nursing-home-type patients under the National Health Act 1973, or other agreed fee, less the residential care amount, unless:

 

(c)           the Commission has granted an exemption under paragraph 10.4.1;

             

in which case the Commission will accept financial responsibility for the full amount of the hospital charge.

 

9.3.3  Nothing in this Part is to be taken to permit payments to be made by the Commonwealth under both the Act and either the Aged Care Act 1997 or the National Health Act 1953 in respect of the same amount for which the Commonwealth has become liable in respect of nursing-home-type care under these Principles or the Aged Care Act 1997 or the National Health Act 1953.

 

9.5       Convalescent care

9.5.1       Subject to prior approval and subject to paragraph 9.2.5, the Commission will accept financial responsibility for the costs of convalescent care for an entitled person at an institution for a maximum of 21 days during any financial year.

 

9.6       Other matters

9.6.1       The Commission may withdraw its approval, at any time, for an entitled person’s continued inpatient treatment in a hospital or other institution.

 

PART 10 — RESIDENTIAL CARE

Part A — residential care not involving residential care (respite)

Note: this heading is intended to be an aid in interpretation.

 

10.1     Residential care arrangements

 

10.1.1  Residential care may be provided in accordance with this Part to:

 

(a)           a person who has a current valid Gold Card; or

(b)                           a person who has a current valid White Card.

Note :‘residential care is defined in paragraph 1.4.1.

 

10.1.2  Subject to paragraph 10.1.3 and paragraph 10.1.5, a person referred to in paragraph 10.1.1 may be provided with residential care under the Aged Care Act 1997and the Principles.

 

10.1.3  Upon the Commonwealth becoming liable to pay an amount under the Aged Care Act 1997 in respect of residential care for a person referred to in paragraph 10.1.1, the Commission is taken to have:

 

(a)           arranged for the provision of that residential care in accordance with this Part; and

 

(b)           accepted financial responsibility for that amount.

Note:       The effect of paragraph 10.1.3 is to provide for payment to be made under the Act instead of the Aged Care Act 1997.  Section 96-10 of the Aged Care Act 1997 provides that subsidies payable under Chapter 3 of the Aged Care Act 1997 in respect of treatment under Division 4 of Part 3 of Chapter 6 of the Act are not payable as an automatic appropriation out of the Consolidated Revenue Fund under the Aged Care Act 1997 but are payable out of that Fund in accordance with the relevant appropriation provisions relating to the arrangement of treatment by the Commission under the Act.

 

10.1.4  Paragraph 10.1.3 does not permit payments to be made by the Commonwealth under both the Act and the Aged Care Act 1997 in respect of the same amount for which the Commonwealth has become liable.

 

10.1.5     Despite paragraph 10.1.3, where residential care is provided to an entitled person under the Aged Care Act 1997 and the Commonwealth is not liable to pay an amount under that Act in respect of an amount incurred by the entitled person in relation to that care, the Commission may accept financial liability for any such amount incurred by the entitled person where the Principles so provide.

 

Note:under the Aged Care Act 1997 the Commonwealth is not necessarily liable to pay resident fees such as the residential care amount.  Liability to pay that amount may be accepted by the Commission under the Principles.

10.4     Payment of residential care amount for certain entitled members with dependants

10.4.1  The Commission may, in exceptional circumstances, accept financial responsibility for the residential care amount for an entitled member who:

 

(a)           has a dependant; and

 

(b)           is receiving a high level of residential care because of a service injury or a service disease or both.

 

 

Part B — residential care involving residential care (respite)

 

Note (1): this heading is intended to be an aid in interpretation.

Note (2): in Part B respite admission and residential care (respite) are interchangeable terms.

 

10.6            Residential care (respite) arrangements

 

10.6.1              residential care (respite) may be provided to an entitled person in accordance with this Part.

 

Note: residential care (respite) includes residential care (28 day respite) under the MRCA Home Care Program.

 

10.6.2              The Commission may, in accordance with the following Table and subject to this Part, accept financial liability for the provision of residential care (respite) to an entitled person for a period not exceeding 63 days in a Financial year or not exceeding such further period in a Financial year for which residential care provided as respite to the person is permitted under the Residential Care Subsidy Principles.

 

Note (1): in calculating the maximum period of residential care (respite) available to an entitled person for which the Commission may meet certain costs, periods of residential care (28 day respite) (where the Commission paid the residential care amount) and in-home respite will be counted.

 

Note (2) in Part B respite admission and residential care (respite) are interchangeable terms and residential care (respite) includes residential care (28 day) respite.

 

Note (4): the Residential Care Subsidy Principles (Principles) are made under subsection 96-1 (1) of the Aged Care Act 1997.  Under Part 7 of the Principles the Secretary may increase the number of days a person may be provided with residential care as respite care by 21.

 


 

 

LIMITS OF FINANCIAL RESPONSIBILITY ACCEPTED BY THE COMMISSION FOR RESPITE ADMISSION

 

category of patient

 

type of care; max.period of care permitted; type of care costs accepted

type of care; max.period of care permitted; type of care costs accepted

 

 

 

 

 

 

 

 

residential care (28 day respite)

 

 

up to 28 days (inclusive) in a Financial year

 

residential care (respite) other than residential care (28 day respite)

 

upon an entitled person exhausting 28 days of residential care (28 day respite) in a Financial yearbetween and including 29 to 63 days* in that Financial year

entitled person

RCS + RCA

RCS

 

 

For the purposes of this table:

 

‘RCA’ means the Commission will accept financial responsibility for the residential care amount.

 

‘RCS’ means the Commission will accept financial responsibility for the residential care subsidy.

 

‘RCS + RCA’ means the Commission will accept financial responsibility for the residential care subsidy  and the residential care amount.

 

* or for such further period permitted under the Residential Care Subsidy Principles.

 

10.6.3           Where the Commission could accept financial liability for a residential care amount otherwise payable by an entitled person in respect of a day in residential care, but does not accept liability because the entitled person chooses to accept that liability , then that day:

 

(a) is not to be taken into account in calculating if the person has been a respite admission for 63 days or such further period permitted under the Residential Care Subsidy Principles; and

 

(b) is not to be taken into account in calculating if the person has been provided with in-home respite for a period exceeding 28 days in a Financial year.

 

10.6.4           Where the Commission accepts financial liability for a residential care amount otherwise payable by an entitled person in respect of a day in residential care in a Financial year, then that day is to be taken into account in calculating if the person would receive in-home respite for more than 28 days in that Financial year.

 

10.6.5           Where the Commission accepts financial liability for the provision of in-home respite to an entitled person on a day, then that day is to be taken into account in calculating if the person has been a respite admission for 63 days (or such further period permitted under the Residential Care Subsidy Principles).

 

10.6.6           Where the Commission accepts financial liability for the provision of emergency short term home relief on a day, then that day is not to be taken into account in calculating if the person has been a respite admission for 63 days (or such further period permitted under the Residential Care Subsidy Principles ) or if the person has received in-home respite for more than 28 days.

 

10.6.7 (1)    For the purposes of paragraphs 10.6.1 to 10.6.6 (inclusive) and subject to paragraph (2), a             day means:

 

                            (a) in relation to residential care (respite) — a period of 24 hours;or

                            (b) in relation to in-home respite — a period of 7 hours.

 

(2)     For the purpose of determining if the limit of days for residential care (respite) has been reached by reference to the number of days an entitled person spent in in-home respite, a day of 7 hours in in-home respite is taken to have been a day of 24 hours, and for the purpose of determining if the limit of days for in-home respite has been reached by reference to the number of days an entitled person spent in residential care (respite), a day of 24 hours in residential care (respite), is taken to have been a day of 7 hours.

           

Note: the "limit of days" for residential care (respite) or for in-home respite means the maximum number of days for which the Commission may accept financial liability for - in the case of residential care (respite), the residential care subsidy or the residential care subsidy and the residential care amount, or for - in the case of in-home respite, the cost of respite

 

                10.6.8     Upon the Commonwealth or an entitled person becoming liable to pay an amount under the Aged Care Act 1997 in respect of residential care (respite) provided to that person and the Commission assuming financial responsibility for that amount, the Commission is taken to have arranged for the provision of that residential care (respite) to that entitled person in accordance with this Part.

                Note (1): the effect of paragraph 10.6.8 is to provide for payment to be made under the Act instead of the Aged Care Act 1997.  Section 96-10 of the Aged Care Act 1997 provides that subsidies payable under Chapter 3 of the Aged Care Act 1997 in respect of treatment under Division 4 of Part 3 of Chapter 6 of the Act are not payable as an automatic appropriation out of the Consolidated Revenue Fund under the Aged Care Act 1997 but are payable out of that Fund in accordance with the relevant appropriation provisions relating to the arrangement of treatment by the Commission under the Act.

 

Note (2): the amount an entitled person could be liable to pay for residential care (respite) is the residential care amount, being a resident's contribution to his or her care.

 

                10.6.9  Nothing in this Part is to be taken to permit payments to be made by the Commonwealth under both the Act and the Aged Care Act 1997 in respect of the same amount for which the Commonwealth has become liable in respect of residential care (respite)  under these Principles or the Aged Care Act 1997.

 

                            Part C — respite admissions not involving residential care (respite)

                           

                            Note (1): this heading is intended to be an aid in interpretation.

                            Note (2): an example of a respite admission not involving residential care (respite) would be an admission to a hospital.  The definition of residential care does not include hospital care.

 

                   10.8  The Commission may accept, in whole or in part, financial responsibility for respite for a maximum period of 28 days in a Financial year in an institution in respect of which a residential care subsidy is not payable if, in the opinion of the Commission, it is a cost-effective and appropriate alternative to residential care (respite) under paragraph 10.6.1 and to Respite Care under the MRCA Home Care Program.

 


 

PART 11 — THE PROVISION OF REHABILITATION APPLIANCES

11.1     Rehabilitation Appliances Program

11.1.1     The Commission may provide:

 

(a)        surgical appliances; and

 

(b)        appliances for self-help and rehabilitation purposes;

 

unless those appliances could be provided by the Commission under a Part of the Act other than Part 3 of Chapter 6 of the Act.

 

Note: appliances could be provided as part of a rehabilitation program under Chapter 3 of the Act or as a modification to a motor vehicle under Chapter 4 of the Act.

 

11.1.2     The aim of the Rehabilitation Appliances Program is to restore, facilitate or maintain functional independence and/or minimise disability or dysfunction as part of the provision of quality care to entitled persons.

 

11.1.3     Appliances shall be provided:

 

(a)        according to an assessed clinically indicated need; and

 

(b)        in an efficient manner of delivery; and

 

(c)        towards meeting health care objectives; and

 

(d)        in a cost effective manner; and

 

(e)        on a timely basis.

 

11.1.4     An appliance that is provided should be:

 

(a)        appropriate for its purpose;and

 

(b)        safe for the particular entitled beneficiary; and

 

(c)        part of the overall management of health care for the entitled person;

 

but should not be an item that is customarily used for domestic purposes and would be used merely for such a purpose by the entitled person.

 

11.2     Supply of rehabilitation appliances

11.2.1     Unless otherwise indicated in these Principles, the Commission will arrange the supply of rehabilitation appliances on the condition that these are returned when no longer needed or if the Commission so requests.

 

11.2.2     Subject to principle 3.4 and paragraph 11.4.1, the Commission will not be financially responsible for the supply of an appliance without prior approval.

 

11.3     Restrictions on the supply of certain items

11.3.1 Subject to this Part, the Commission will provide or accept financial responsibility for the following appliances only to entitled members who have a medically assessed need for these items due to a service injury or service disease:

 

(a)        the supply of electric wheelchairs or electric scooters;

 

(b)        the supply of a guide dog, provided that the Commission will not be responsible for costs associated with keeping the dog;

 

(c)        the supply of special vehicle driving controls and devices, if the entitled member owns the vehicle and is licensed under relevant State or Territory law to drive a modified vehicle.

 

11.3.2     Subject to this Part, the Commission will provide or accept financial responsibility for the provision of electronic communication equipment only to entitled members who are:

 

(a)        legally blind; or

 

(b)        severely handicapped.

 

11.3.3     For the purposes of paragraph 11.3.2, a legally blind entitled member means an entitled member:

 

(a)        whose legal blindness is service injury or service disease; and

 

(b)        who has a medically assessed need for the electronic communication equipment; and

 

(c)        who has been assessed by the Commission as being able to benefit from use of the electronic communication equipment.

 

11.3.4     For the purposes of paragraph 11.3.2, a severely handicapped entitled member means an entitled member:

 

(a)       whose severe handicap was a service injury or service disease; and

 

(b)      who has a medically assessed need for the electronic communication equipment; and

 

(c)       who has been assessed by the Commission as being able to benefit from the use of the equipment because it would substantially improve the member's:

 

(i)        communication skills; and

 

(ii)       quality of life.

 

11.3.6     The Commission will not approve the supply of a rehabilitation appliance to an entitled person in an institution where:

 

(a)        the Commission is satisfied that the appliance should be supplied by the institution because of Commonwealth, State or Territory legislation under which the institution is registered;or

 

(b)        the Commission is satisfied that the appliance should be supplied by the institution as the result of charges made or subsidies received by the institution under Commonwealth, State or Territory legislation; or

 

(c)        installation of the appliance necessitates structural alteration to any part of the institution.

 

11.3.7     Subject to other conditions specified in this Part, the Commission may approve the installation or the attachment of a rehabilitation appliance to property when:

 

(a)        the installation or the attachment conforms to Commonwealth, State or Territory laws relating to alterations to property; and

 

(b)        the property owner has given approval and an undertaking not to seek compensation for restoration of the property when the appliance is no longer required by the entitled person to whom the aid was supplied.

 

11.3.8     Subject to this Part, the Commission may provide or accept financial responsibility for the installation of a telephone deaf aid and/or touch phone and the rental of the aid for the first year, in the workplace of an entitled member who has a medically assessed need for these items because of a service injury or service disease.

 

11.4     Visual aids

11.4.1     The Commission will accept financial responsibility for visual aids dispensed on a prescription of an ophthalmologist or an optometrist in accordance with arrangements entered into between the Commission and suppliers.

 

11.4.2     Visual aids may be prescribed from the Schedule of Prescribable Items.

Note:      The Schedule of Prescribable Items is made by the Commission under paragraph 7.4.2

 

11.4.3     Prior approval is required for the prescription of non-Schedule items except in the circumstances referred to in paragraph 11.4.6.

 

11.4.4     Subject to paragraph 11.4.5, in any two year period, the Commission shall not provide an entitled person with:

 

(a)        more than one pair of distance spectacles and one pair of readers; or

 

(b)       more than one pair of bifocals, trifocals or progressive power lenses.

 

11.4.5     The Commission will provide an entitled person with renewed lenses before the expiration of two years if:

 

(a)        in the opinion of the treating practitioner, there has been a change in;

 

(i)         the person’s refraction; or

 

(ii)        the condition of the person’s eyes,

 

that necessitates new lenses; or

 

(b)        there has been accidental loss or breakage.

 

11.4.6     If an entitled person chooses spectacle frames or lenses that differ from those listed in the Schedule of Prescribable Items, or that have not been medically prescribed, the Commission will accept financial responsibility only to the financial limits set out in the schedule.

 

11.5     Hearing aids

11.5.1     The Commission will approve the supply of a spectacle hearing aid when it is the only type of hearing aid appropriate and the person is entitled to the treatment:

 

(a)        of all injuries or diseases; or

 

(b)        of deafness that is a service injury or service disease; or

 

(c)        of a visual defect that is a service injury or service disease and the need for a spectacle hearing aid arises from the person’s inability to accommodate spectacles and a separate hearing aid.

 

11.5.2     Where a person who has a hearing defect that is a service injury or service disease is provided with a spectacle hearing aid under paragraph 11.5.1:

 

(a)        new lenses will be provided; or

 

(b)        the existing spectacle lenses will be fitted as part of the aid.

 

11.5.3     The Commission will not be responsible, under paragraph 11.5.2, for the further supply or the fitting of lenses if the person is not entitled to the supply of spectacles.

 

11.5.4   Subject to prior approval, the Commission may accept financial responsibility for the supply of a hearing aid from an audiology provider if the hearing aid is unable to be supplied to the entitled person under the Hearing Services Administration Act 1997 or the Hearing Services Act 1991.

 

11.5.5  The Commission may accept financial responsibility for service charges in respect of a hearing aid that has been supplied under paragraph 11.5.4.

 

11.5.6     The Commission may accept financial responsibility for service charges in respect of a hearing aid following the supply of that hearing aid under paragraph 11.5.4 or 11.5.5.

 

 

 

 


Leave 1 page space as amendment divider


 

11.6     Other rehabilitation appliances

11.6.1     Subject to this Part, the Commission may arrange for a wig to be supplied to an entitled person who:

 

(a)        became bald as a result of a service injury or service disease or as a result of the treatment of a service injury or service disease; or

 

(b)        requires a wig as part of medical treatment for disfigurement.

 

11.6.2     The Commission will not accept financial responsibility for the cleaning and setting of a wig.

 

11.6.3     Subject to this Part, the Commission may:

 

(a)        provide medically suitable footwear as an aid; or

 

(b)        approve the repair of an entitled person’s own footwear as part of medically prescribed alterations to the footwear.

 

11.6.4     Where the Commission approves the provision of stoma appliances and consumables, the provision will be through:

 

(a)        a stoma association; or

 

(b)        the Pharmaceutical Benefits Scheme; or

 

(c)        the MRCA Pharmaceutical Benefits Scheme.

 

11.6.5     The Commission will accept financial responsibility for the cost of membership of a stoma association and for the cost of postage of stoma supplies.

 

11.7     Repair and replacement

11.7.1     The Commission may approve the provision of more than one of the same rehabilitation appliance if the entitled person depends completely on the appliance, and:

 

(a)        it is necessary to maintain the appliance in a hygienic condition because of domestic or occupational circumstances; or

 

(b)        the entitled person lives in an isolated country area and would be handicapped by loss or breakage; or

 

(c)        there are other circumstances where the Commission considers it reasonable to do so.

 

11.7.2     Subject to paragraphs 11.7.6 and 11.7.7, the Commission will not be financially responsible for the alteration to, or the repair of, a treatment aid without prior approval.

 

11.7.3     The Commission will not be financially responsible for, or reimburse, the cost of an alteration to, or a repair of, a rehabilitation appliance for which it has not accepted financial responsibility, unless there are circumstances where the Commission considers it reasonable to accept financial responsibility.

 

11.7.4     The Commission will not be financially responsible for repair or replacement of a rehabilitation appliance for a non service injury or disease injury or disease while an entitled person is travelling overseas.

 

11.7.5     Prior approval will be given for the repair or replacement of an appliance where repair or renewal is necessary because:

 

(a)        the appliance was damaged by normal wear and tear;

 

(b)        the appliance inadvertently was damaged or lost; or

 

(c)        the health-care practitioner treating the entitled person considers that a replacement is required because the person’s condition has changed.

 

11.7.6     The Commission will not give approval for the repair or replacement of an appliance if repair or renewal is necessary as the result of:

 

(a)           a wilful act of the entitled person using or wearing the appliance; or

 

(b)           a negligent act of the entitled person using or wearing the appliance and the person has damaged or lost a similar appliance in the past as a result of negligence or wilfulness.

 

11.7.7     Prior approval is not required for repairs to spectacles.

 

11.8     Treatment aids from hospitals

11.8.1     The Commission may provide, or accept financial responsibility for, treatment aids as part of inpatient treatment where the aids expedite discharge from hospital.

 

11.8.2     The conditions for the supply of treatment aids are the same as those normally applied by the hospitals for patients not covered by these Principles.

 

11.8.3     The Commission will not provide, or accept financial responsibility for, a treatment aid as part of inpatient or outpatient treatment where the treatment solely comprises the provision of the treatment aid.

 

11.9     Provision of aids and appliances for accident prevention and personal safety

 

11.9.1  Subject to this Principle, the Commission may assist in providing aids and appliances for accident prevention and personal safety for an entitled person by approving financial assistance towards the cost of such appliances to an upper limit of $163 in a calendar year.

 

11.9.2  The Commission may give approval under paragraph 11.9.1 only if it has received a report from a home and safety assessor and the Commission is satisfied that the aid or appliance for which assistance is sought:

  

(a)           is needed by the person for accident prevention or personal safety as part of the person’s preventive health care management; and

 

(b)           is appropriate for its purpose; and

 

(c)           is safe and appropriate for the person’s particular circumstances; and

 

(d)           is customarily used for domestic purposes and would be used for such purposes by the person; and

 

(e)           would be provided or installed efficiently, cost effectively, and on a timely basis.

 

11.9.3  The Commission may enter into arrangements with a person or persons:

 

(a)           to provide the Commission with reports from home and safety assessors; and

 

(b)           for the provision of aids and appliances for accident prevention and personal safety.

 

11.9.4  Subject to Principle 3.4, the Commonwealth will not be financially responsible, either partly or wholly, for the purchase, supply, or installation of an aid or appliance for accident prevention and personal safety unless:

 

(a)           financial assistance has been approved under paragraph 11.9.1; and

 

(b)           the appliance is provided under an arrangement entered into under paragraph 11.9.3.

 

11.9.5  The Commission cannot accept financial responsibility, either partly or wholly, for the purchase, supply, or installation of an aid or appliance for accident prevention and personal safety if it is satisfied that:

 

(a)           the appliance can reasonably be obtained under another Commonwealth, State, or Territory program; or

 

(b)           the appliance should be provided by the owner of a self-care unit, or retirement village, or institution in which the entitled person resides; or

 

(c)           the installation of the appliance would result in structural alteration to any part of the institution in which the person resides.

 

11.9.6  If the relevant aid or appliance requires attachment to real property in such manner that it becomes a fixture or involves alteration to the structure of the property, the Commission may give approval under paragraph 11.9.1 only if it is satisfied that:

 

(a)        such attachment or alteration will not breach, and  will be in accordance with, relevant Commonwealth, State, or Territory laws; and

 

(b)        the owner of the property has:

 

(i)            given approval for the attachment; and

 

(ii)           undertaken not to seek compensation for restoration of the property.

 

11.9.7  The Commonwealth will not be financially responsible for the maintenance or repair of any aid or appliance for which the Commission has approved financial assistance under this Principle.

 

11.9.8  The Commonwealth will not be responsible for any damage caused by:

 

(a)           the installation, operation, non-operation, use, or misuse of an aid or appliance for which the Commission has approved financial assistance under this Principle; or

 

(b)           any delay in installing such an aid or appliance or approving financial assistance under this Principle.


 

PART 12 — OTHER TREATMENT MATTERS

12.1     Ambulance transport

12.1.1     With the exception of arrangements for medical emergency under paragraph 12.1.4 and special arrangements under paragraph 12.1.5, prior approval must be obtained in all cases before ambulance transport is used by an entitled person.

 

12.1.2     Approval for ambulance transport normally will be given where the entitled person:

 

(a)        is a stretcher case;or

 

(b)        requires treatment during transport;or

 

(c)        is grossly disfigured; or

 

(d)        is incontinent to a degree that precludes the use of other forms of transport.

 

12.1.3     Other than in exceptional circumstances, air ambulance will be approved only to transport an entitled person with acute medical and surgical complaints for admission to, or discharge from, a hospital.

 

12.1.4     The Commission will accept financial responsibility for the use of ambulance transport in a medical emergency for an entitled person if an office of the Department is notified on the first working day after the ambulance transport is used or as soon thereafter as is reasonably practicable.

 

12.1.5     Prior approval for ambulance transport for entitled persons is not required where the transport is provided under arrangements between the ambulance service provider and the Commission.

 

12.2     Treatment under Medicare

12.2.1     Entitled persons may choose to have their treatment arranged through the Department or under Medicare.

 

12.2.2     Subject to these Principles, entitled persons who are treated under Medicare arrangements may also receive services that are not covered by Medicare at the Commission’s expense.

 

12.2.3     When part or all of the cost of a treatment item has been paid as a Medicare benefit, the Commission will not pay for the same professional or ancillary service regardless of the person’s entitlement under the Act.

 

12.4     Prejudicial or unsafe acts or omissions by patients

12.4.1     The Commission may refuse to be financially responsible for, or provide treatment to, or any further treatment to, an entitled person who, by an act or omission, deliberately prejudices his or her own, or a fellow patient’s, treatment or the safety of persons providing treatment.

12.6     Recovery of moneys

12.6.1     Where a payment has been made to any person or body, purportedly as payment for treatment, the Commission may recover (up to the extent that the payment exceeds the amount, if any, that should have been paid to that person or body) any moneys, the payment of which was induced or affected at all by:

 

(a)        any misrepresentation; or

 

(b)        any mistake of fact; or

 

(c)        any mistake of law; or

 

(d)        any other cause.

 

12.6.2     Further to paragraph 12.6.1, the Commission may recover moneys for any excess amounts that should not have been paid to that person or body:

 

(a)        in a single demand; or

 

(b)        by instalments; or

 

(c)        subject to section 317 of the Act, by offsetting moneys for any excess amounts against any later claims for payment by that person or body; or

Note:      Section 317 provides, in effect, that where amounts have been overpaid, the Commission may, if the person agrees, offset money owed against later payments.

 

(d)        by a combination of any of these methods of recovery.

 

12.6.3     Nothing in this principle is to be taken to restrict any other right or action for recovery of moneys.

 


 

Schedule 1      Transitional Provisions

 

 

 

(1)     MRCA Treatment Principles No. M21 of 2004

 

(a) any arrangement entered into, or taken to have been entered into, by the Commission or the Department (on behalf of the Commission) with a health provider, under MRCA Instrument No.3 of 2004 entitled "Determination for Providing Treatment" (hereafter called MRCA Instrument No.3 of 2004) being an arrangement that is in force immediately before the commencement of these Principles ¾ is taken to have been entered into under these Principles.

 

(b) any action taken (eg issue of a notice, grant of approval, giving of a receipt), and any document produced in the course of that action, by the Commission, the Department (on behalf of the Commission), a health provider or an entitled person, under MRCA Instrument No.3 of 2004, being action or a document that is in effect or in force immediately before the commencement of these Principles ¾ is deemed, respectively, to have been taken or produced under these Principles.

 

(c) a Scheme (eg Local Medical Officer Scheme, Local Dental Officer Scheme) prepared by the Repatriation Commission under the Treatment Principles under section 90 of the Veterans' Entitlements Act 1986, that is in force immediately before the commencement of these Principles and is referred to in these Principles,  is taken to have been made by the Commission under these Principles.

 

(d) where, before the commencement of these Principles but on or after

1 July 2004, the Commonwealth paid an amount of $3 ($3 payment) to a medical practitioner for a medical consultation or medical procedure in respect of an entitled person and the $3 payment was in addition to any other amount the Commonwealth paid the medical practitioner and the $3 payment was not authorised under the MRCA Instrument No.3 of 2004 or under the Act and was made in anticipation of the introduction of the MRCA access payment, then on the commencement of these Principles, a $3 payment is taken to have been made under these Principles as if it were a MRCA access payment in respect of the consultation or procedure.

 


 

Schedule 2      MRCA Medical Fee Schedule

 

 

 

                                              MRCA

Medical Fee Schedule

 

                                                1 January 2005

MRCA Medical Fees can be claimed by medical specialists who provide services to current and former members of the Australian Defence Force (ADF) and dependants of deceased members of the ADF. Where a specialist agrees to claim the MRCA Medical Fee for a service provided, no further claim can be levied against that member or dependant.

 

MRCA Medical Fee assessments and calculations are based on Medicare assessment rules.

 


 

Item

Scheduled

Increase

Item

Scheduled

Increase

Item

Scheduled

Increase

Item

Scheduled

Increase

 

number

fee

%

number

fee

%

number

fee

%

number

fee

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

00104

83.50

 

00338

243.45

 

00534

635.65

 

11204

110.20

 

 

00105

41.85

 

00342

48.15

 

00536

706.35

 

11205

110.20

 

 

00106

69.30

 

00344

63.95

 

00820

135.70

 

11210

110.20

 

 

00107

122.40

 

00346

94.45

 

00822

203.60

 

11211

110.20

 

 

00108

77.45

 

00348

51.05

 

00823

271.40

 

11212

71.40

 

 

00110

147.25

 

00350

114.85

 

00825

97.50

 

11215

125.20

 

 

00116

73.70

 

00352

51.05

 

00826

155.50

 

11218

154.70

 

 

00119

41.85

 

00353

48.60

 

00828

213.45

 

11221

69.00

 

 

00122

178.70

 

00355

97.05

 

00830

135.70

 

11222

69.00

 

 

00128

108.05

 

00356

142.30

 

00832

203.60

 

11224

41.60

 

 

00131

77.80

 

00357

196.40

 

00834

271.40

 

11225

41.60

 

 

00160

211.90

 

00358

239.25

 

00835

97.50

 

11235

124.90

 

 

00161

353.10

 

00364

42.25

 

00837

155.50

 

11237

82.85

 

 

00162

494.25

 

00366

84.40

 

00838

213.45

 

11240

82.85

 

 

00163

635.65

 

00367

123.70

 

00855

135.70

 

11241

105.55

 

 

00164

706.35

 

00369

170.80

 

00857

203.60

 

11242

81.60