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:

“aboriginal health worker” means a person who is qualified as an aboriginal health worker after undertaking a course in Aboriginal and Torres Strait Islander Health, provided by an institution recognised by the Department of Health and Ageing as suitable for providing a course of that nature, and who obtained a Certificate Level III (or higher) under the course.

“Aboriginal Health Worker Care Co-ordination treatment” means treatment provided by an aboriginal health worker to an entitled person under the Coordinated Veterans' Care Program, comprised of:

(a) implementing the GPMP for the person under the Program — in particular co-ordinating treatment services under the GPMP;

(b) liaising, in relation to the GPMP, with the LMO who manages the GPMP for the person;

(c) performing such other functions under the program that the aboriginal health worker has under the Notes for Coordinated Veterans' Care Program Providers.

“ACPMH treatment” means action taken with a view to maintaining an entitled member in mental health and includes:

(a) training members of the Defence Force or staff made available under section 382 of the Act, or both, in the mental health care disciplines that could benefit the mental health of an entitled member; and

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

(i) members of the Defence Force who are staff-managers; and

(ii) staff made available under section 382 of the Act; and

(iii) an entitled member; and

(d) conducting mental injury or disease health care policy research with the outcomes of that research being applied to the benefit of the health of an entitled member.

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

Note (2): the term “member” is defined in these Principles so as to include “former member“ and the term “Defence Force” is defined in s.5 of the Act.

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

“admission date” means the date on which an LMO records in writing (including in electronic form) that the LMO has decided an entitled person may participate in the Coordinated Veterans' Care Program.

“admitting LMO”, in relation to an entitled person in the Coordinated Veterans' Care Program, means the LMO who decided an entitled person may participate in the Coordinated Veterans' Care Program.

“allied health provider” means a category of provider mentioned in the Table in 7.1A.1.

"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) a Home Care service (category A); or

(b) a Home Care service (category B); or

(d) a limited MHC-type service;

to an entitled person, whether by the approved provider or a sub-contractor engaged by it.

“Australian Centre for Posttraumatic Mental Health” and “ACPMH” mean the Australian Centre for Posttraumatic Mental Health Incorporated.

“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”, in relation to transition care, has the meaning it has in the Aged Care Act 1997.

Note: the Aged Care Act 1997 can be found on COMLAW: http://www.comlaw.gov.au

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

“carer” means 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’ Health” means the entity in the University of Queensland, Herston Campus, operated by the Board of Management.

“Chief Executive Medicare” has the meaning it has in the Human Services (Medicare) Act 1973.

“clinical psychologist” means a psychologist:

(a) who has been given a provider number in respect of being a psychologist; and

(b) who, in the opinion of an employee of, or consultant to, the Department or the Department of Human Services, has appropriate qualifications in clinical psychology and practises as a clinical psychologist.

“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 Aged Care Package” means “community care” under section 45-3 of the Aged Care Act 1997 in force from time to time (the Act) for which an approved provider under the Act is, on the day community care is provided by the provider to a former prisoner of war or an entitled member awarded the Victoria Cross for Australia, eligible for community care subsidy under the Act.

Note 1: the Aged Care Act 1997 and the Community Care Subsidy Principles 1997 can be found on COMLAW: http://www.comlaw.gov.au

Note 2: the Community Care Subsidy Principles 1997 may specify care that is/is not community care under the Aged Care Act 1997.

“community nurse” means a registered nurse or enrolled nurse who works in a community nursing setting and who is employed or engaged by a DVA-contracted community nursing provider.

“Community Nurse Care Co-ordination treatment” means

treatment provided by a community nurse to an entitled person under the Coordinated Veterans' Care Program, comprised of:

(a) implementing the GPMP for the person under the Program — in particular co-ordinating treatment services under the GPMP; and

(b) liaising, in relation to the GPMP, with the LMO who manages the GPMP for the person.

"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 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).

“consumable rehabilitation appliance” means an appliance with a short term function and includes appliances such as continence products.

“Contracted Day Procedure Centre” means premises:

(a) at which any patient is admitted and discharged on the same day for medical, surgical or other treatment; and

(b) operated by a person contracted to the Commission, the Repatriation Commission or the Department in respect of treatment provided at the premises to entitled persons;

but does not include any of the following premises:

(d) a public hospital or health service under the control of a public health organisation;

(e) a private hospital;

(f) a nursing home;

(g) a residential rehabilitation establishment.

“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.

“Coordinated Veterans' Care Program” means the treatment program of that name set out in Part 6A of these Principles and in the Notes for Coordinated Veterans' Care Program Providers that aims to reduce the need for hospitalisation among Gold Card members of the veteran and defence force community and improve their social well-being. In particular the program has the following main features:

assessment - a Local Medical Officer (LMO) will assess a person with complex care needs due to chronic disease to see if the person would benefit from the clinical care services under the program and ascertain if the person meets the program’s eligibility criteria;
consent – a person needs to consent in writing to participation in the program and the LMO needs to record that consent. As treatment is being provided it is the LMO’s responsibility to ensure a potential participant in the program understands the nature of the program and that the person’s personal details that are relevant to the person’s treatment under the program may be provided to bodies and individuals such as the Department, the Department of Human Services and health care providers, who have a need for the information in connection with the person’s treatment under the program.
care plan – the LMO will prepare a comprehensive care plan (GPMP) for a person the LMO admits to the program;
consultation - the person will be consulted in the preparation of the care plan and its review;
implementation and co-ordination - the LMO’s practice nurse (or a community nurse via a DVA-contracted community nursing provider, or an aboriginal health worker, if more appropriate) will implement the care plan and, in particular, co-ordinate services under the plan.

“Coordinated Veterans' Care Program treatment” means:

(a) LMO Care Leadership treatment; or

(b) Practice Nurse Care Co-ordination treatment; or

(d) Aboriginal Health Worker Care Co-ordination treatment.

"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.

“Day Procedure Centre” means premises that would be Contracted Day Procedure Centre premises if the operator of the premises was contracted to the Commission, the Repatriation Commission or the Department.

“DVA-contracted community nursing provider” means a community nursing provider who has entered into a Deed of Standing Offer with the Commission to provide community nursing services to entitled persons.

“DVA document” means a document prepared in the Department and available on the Internet at:

http://www.dva.gov.au/Pages/home.aspx

“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 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

(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.

“dentist” means a person registered or licensed as a dentist under a law of a State or Territory that provides for the registration or licensing of dentists but does not include a person so registered or licensed:

(a) whose registration, or licence to practise, as a dentist in any State or Territory has been suspended, or cancelled, following an inquiry relating to his or her conduct; and

(b) who has not, after that suspension or cancellation, again been authorised to register or practise as a dentist in that State or Territory.

“enrolled nurse” means a person who is registered under a law of a State or Territory or of the Commonwealth to practise as an enrolled nurse.

“Extended Aged Care at Home Package” means “flexible care” as defined in section 49-3 of the Aged Care Act 1997 in force from time to time (the Act):

(a) for which an approved provider under the Act is, on the day flexible care is provided by the provider to a former prisoner of war or an entitled member awarded the Victoria Cross for Australia, eligible for flexible care subsidy under the Act; and

(b) comprised of the flexible care described in the Flexible Care Subsidy Principles 1997 as “extended aged care at home” or “extended aged care at home - dementia”.

Note 1: the Aged Care Act 1997 and the Flexible Care Subsidy Principles 1997 can be found on COMLAW: http://www.comlaw.gov.au

Note 2: the Flexible Care Subsidy Principles 1997 may specify care for which flexible care subsidy under the Act may be payable.

“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.

“Department of Human Services” means the Department administered by the Minister administering the Human Services (Medicare) Act 1973.

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

“diabetes educator” means a person who:

(a) is credentialled as a diabetes educator by the Australian Diabetes Educators Association (ADEA); and

(b) is a member of, or eligible for membership of, the ADEA.

“diabetes educator services” means a program of education about diabetes with an emphasis on self-care, provided by a diabetes educator to a person with diabetes.

"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

“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

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:

(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 DVA-contracted 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

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 a Home Care service (category A), Home Care service (category B) and Home Care service (category C) 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) or Home Care service (category C) 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) or Home Care service (category C) 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.

“Fee Schedule” means a DVA document approved by the Repatriation Commission, the Commission, or a member of the Repatriation Commission or of the Commission, or by the Secretary to the Department, with the words “Fees” and ‘Schedule”, in relation to a category of health care provider, in the title to the document, that sets out the terms on which, and the conditions subject to which, the Commission will accept financial responsibility for treatment provided to an entitled person by the health care provider the subject of the document.

Note: the DVA documents called Fee Schedules set out amounts the Department will pay for health care services and can designate whether a service required the prior approval of the Commission before it could be provided.

“flexible care” has the meaning it has in section 49‑3 of the Aged Care Act 1997.

“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.

“GPMP” means the care plan prepared by an LMO, in accordance with the Notes for Coordinated Veterans' Care Program Providers, for an entitled person participating in the Coordinated Veterans' Care Program.

Note: “GPMP” is used in the Department of Veterans’ Affairs Fee Schedules for Medical Services (see: paragraph 3.5.1).

“health care provider” means a person who provides treatment to an entitled person in accordance with these Principles.

"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:

(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:

(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.

“Home Care service (category C)” means the provision by an approved provider of a service to an entitled person under the MRCA Home Care Program that is:

(a) pursuant to an LMO Home Care service (category C) Referral and allocated to the provider by a MHC assessment agency; and

(b) aimed at reducing the person’s social isolation by improving their social networks; and

"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 force on the date in Schedule 1”, in relation to a document, means that on the date in Schedule 1 for the document:

(a) if the document may be approved under the Principles by the Commission, the Repatriation Commission or a member of the Commission or Repatriation Commission or by the Secretary to the Department – the document has been so approved.

Note: an example being the Notes for Local Medical Officers (para.1.4.1).

(b) if the document is prepared on behalf of the Commission, the Repatriation Commission or the Department but is not required under the Principles to be approved in a manner in (a) – the document has been approved in a manner in (a).

(c) if the document is not prepared under (b) and is not required under the Principles to be approved in a manner in paragraph (a) – the document exists.

“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.

“institution”, in Part 11, includes:

(a) a retirement village;

(b) a cluster of self-care units.

"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:

(a) is registered under the Notes for Local Medical Officers as a Local Medical Officer and who treats an entitled person in accordance with the terms, and subject to the conditions, in these Principles and in the “Notes for Local Medical Officers”; and

(b) has been given a provider number, in respect of being a medical practitioner, that has not been suspended or revoked.

Note: a provider number may be a number used by the Department and adopted by the Department of Human Services.

“LMO Care Leadership treatment” means treatment provided by an LMO to an entitled person, under the Coordinated Veterans' Care Program, comprised of:

(a) preparing and managing the GPMP for the person under the Program;

(b) overseeing a practice nurse in the implementation of the GPMP — where a practice nurse and not a community nurse or aboriginal health worker or the LMO co-ordinates treatment under the GPMP (Practice Nurse Care Co-ordination treatment);

(c) referring the person to a DVA-contracted community nursing provider for Community Nurse Care Co-ordination treatment or to an aboriginal health worker for Aboriginal Health Worker Care Co-ordination treatment, if appropriate;

(d) performing such other functions under the program that the LMO has under the Notes for Coordinated Veterans' Care Program Providers.

“LMO Home Care service (category C) Referral” means treatment comprised of an LMO preparing a written document that refers an entitled person, who the LMO has admitted to and is treating under the Coordinated Veterans' Care Program, to a MHC assessment agency for assessment for a Home Care service (category C) under the MRCA Home Care Program and which:

(a) is in the form, if any, approved by the Repatriation Commission or Commission; and

(b) is sent to the MHC assessment agency, including as a facsimile message.

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

“MBS” and “Medicare Benefits Schedule” mean, in the context of amounts payable for treatment under the Principles, a Fee Schedule, and in any other context means:

(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.

Note: an example of where “Medicare Benefits Schedule” is used in a non-payment context is paragraph 4.2.1.

“medical practitioner” has 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” has the meaning it has in the Health Insurance Act 1973.

“medicare program” has the meaning it has in the Human Services (Medicare) Act 1973.

"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.

“MHC assessment agency” means a person to whom the Commission has delegated its power to:

(a) assess whether a person needs:

(i) a Home Care service (category A); or

(ii) a Home Care service (category B); or

(iii) a Home Care service (category C;

under the MRCA Home Care Program; and

(b) allocate a service in (a) to an approved provider.

“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

(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 the amount set out in the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services”, in force on the date in Schedule 1, and called the “MRCA Access Payment” — being an additional amount payable by the Department to an LMO for a medical service provided by the LMO to an entitled person in accordance with these Principles and the Notes for Local Medical Officers.

Note: a MRCA Access Payment is an amount additional to any amount otherwise payable by the Department to an LMO for a medical service provided by the LMO to an entitled person in accordance with these Principles and the Notes for Local Medical Officers.

"MRCA Home Care Program" means:

(a) 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.

(b) the treatment program under which the Commission ensures the provision of social support services to entitled persons referred to the program under a LMO Home Care service (category C) Referral.

"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.

“neuropsychologist” means a person who:

(a) specialises in the assessment, diagnosis and treatment of psychological disorders associated with conditions affecting the brain such as difficulties with memory, learning, attention, language, reading, problem-solving, decision-making or other aspects of behaviour and thinking abilities; and

(b) in the opinion of an employee of, or consultant to, the Department or the Department of Human Services, has appropriate qualifications in clinical neuropsychology and practises as a neuropsychologist.

“Notes for Allied Health Providers” means the document approved by the Secretary to the Department entitled “Notes for Allied Health Providers”, and in force on the date in Schedule 1, that sets out the terms on which, and the conditions subject to which, an allied health provider is to provide treatment to an entitled person in order for the Commission to accept financial responsibility for that treatment.

“Notes for Coordinated Veterans' Care Program Providers” means the document approved by the Commission, the Repatriation Commission, or a member of the Commission or Repatriation Commission, or by the Secretary to the Department, entitled “Notes for Coordinated Veterans' Care Program”, and in force on the date in Schedule 1, that sets out the terms on which:

(a) an LMO;

(b) a practice nurse;

(d) an aboriginal health worker;

is to provide treatment to an entitled person under the Coordinated Veterans' Care Program in order for the Commission to accept financial responsibility for that treatment.

“Notes for Local Medical Officers” means the document:

(i) approved by the Commission or a member thereof, the Repatriation Commission or a member thereof, or by the Secretary to the Department, entitled “Notes for Local Medical Officers”; and

(ii) in force on the date in Schedule 1; and

(iii) that sets out the terms on which, and the conditions subject to which, a LMO is to provide treatment to an entitled person in order for the Commission to accept financial responsibility for that treatment, except those parts of the document that deal with the formation of a contractual relationship between a LMO and the Commission or the Department.

Note: the intention is that the treatment provided by a Local Medical Officer (LMO) to an entitled person may be regarded as having been provided in accordance with the Principles and the “Notes for Local Medical Officers” despite the LMO not entering into any arrangement with the Commission or the Department as required by the Notes (without the parts mentioned above omitted). See: paragraph 5.3 of the Notes for Local Medical Officers.

“occupational therapist” means an occupational therapist who has been given a provider number in respect of being an occupational therapist.

“occupational therapist (mental health)” means an occupational therapist:

(a) who has been given a provider number in respect of being an occupational therapist; and

(b) who, in the opinion of an employee of, or consultant to, the Department or the Department of Human Services, has appropriate qualifications in occupational therapy in the area of mental health and who practises as an occupational therapist in the area of mental health.

“Optical Coherence Tomography” means the treatment comprised of a non-contact, non-invasive high resolution imaging technique that provides cross-sectional tomographic images of the ocular microstructure through the thickness of the retina.

"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:

(a) treats an entitled person in accordance with the terms, and subject to the conditions, in these Principles; and

(b) has been given a provider number, in respect of being a medical practitioner, that has not been suspended or revoked.

Note: an other GP, unlike an LMO, does not provide treatment in accordance with the Notes for Local Medical Officers.

Note: a provider number may be a number used by the Department and adopted by the Department of Human Services.

“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;

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

“period of care” in relation to the care provided by:

(a) an LMO; or

(b) a practice nurse; or

(d) a community nurse (via a DVA-contracted community nursing provider);

to an entitled person under the Coordinated Veterans' Care Program (Program), means the period set out in the Notes for Coordinated Veterans' Care Program Providers in relation to the LMO, practice nurse, community nurse or aboriginal health worker, provided that any subsequent period of care by the same LMO is approved by the LMO for the person.

Note 1: the period of care is important for billing purposes. The Notes for Coordinated Veterans' Care Program Providers contain the detail of billing procedures. Generally, for an LMO the period is 3 months commencing on the patient’s admission to the Program and for a community nurse the period is 28 days commencing on date of service. Generally previous care periods with different providers must expire before a new provider can claim for a care period except that, with prior approval, a community nurse can claim for a care period although a previous care period in respect of the relevant entitled person has not expired. A community nurse cannot claim for a period not covered by a period of care provided by an LMO.

Note 2: any period of care by an LMO other than the first period of care commencing on the date the entitled person is admitted to the Program (admission date) or the first period of care as a different LMO for the person (commencing on the date worked out under the Notes for Coordinated Veterans' Care Program Providers, is a subsequent period of care by an LMO and the LMO must approve it. By approving it, the periods of care provided by any care co-ordinator (practice nurse, community nurse or aboriginal health worker) during the period of care approved by the LMO are valid periods of care under the Program (sub-periods of care). A sub-period of care may only be provided under the Program during a period of care under the Program by an LMO.

"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.

“practitioner” has the same meaning as in section 124B of the Health Insurance Act 1973 in force from time to time.

“practice nurse” means a registered nurse or enrolled nurse employed or engaged by an LMO as a nurse in the LMO’s practice.

“Practice Nurse Care Co-ordination treatment” means

treatment provided by a practice nurse to an entitled person, under the Coordinated Veterans' Care Program, comprised of:

(a) implementing the GPMP for the person under the Program — in particular co-ordinating treatment services under the GPMP;

(b) liaising, in relation to the GPMP, with the LMO supervising the practice nurse in relation to the implementation of the GPMP;

(c) performing such other functions under the program that the practice nurse has under the Notes for Coordinated Veterans' Care Program Providers.

“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.

“prisoner of war” means an entitled member who was captured by the enemy (including a terrorist) while rendering defence service.

“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;

(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;

(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.

“provider number” means the number:

(a) allocated by:

(i) the Chief Executive Medicare or by his or her delegate or by a person authorised by the Chief Executive Medicare — to a practitioner; or

(ii) the Chief Executive Officer of Medicare Australia under the Medicare Australia Act 1973 — to a practitioner; and

(b) which identifies the practitioner and the places where the practitioner practises his or her profession.

Note: see regulation 2 of the Health Insurance Regulations 1975.

"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.

“provision of a Home Care service (category C) 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 C) to an entitled person.

"psychologist” means a psychologist who has been given a provider number in respect of being a psychologist.

“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.

“RAP National Schedule of Equipment” means the document of that name approved by the Repatriation Commission or the Commission or by a member of the Repatriation Commission or the Commission or by the Secretary to the Department, and in force on the date in Schedule 1, that lists the surgical aids and appliances for self-help and rehabilitation available to an entitled person under the Department’s Rehabilitation Appliances Program.

“registered nurse” means a person who is registered under a law of a State or Territory or of the Commonwealth to practise as a registered nurse.

"Rehabilitation Appliances Program (RAP) National Guidelines"

means the document of that name approved by the Repatriation Commission or the Commission or by a member of the Repatriation Commission or the Commission or by the Secretary to the Department, and in force on the date in Schedule 1, that assists Commission delegates when determining approval for surgical aids and appliances for self-help and rehabilitation (items) available under the Department’s Rehabilitation Appliances Program and which informs prescribers and suppliers of the processes necessary for an item to be provided to an entitled person.

"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:

(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.

“retirement village” has the same meaning it has in the Veterans’ Entitlements Act 1986 and as applied by the Treatment Principles.

Note: retirement village is defined in section 5M of the Veterans’ Entitlements Act1986 (VEA) and is also applied by the Treatment Principles. The intention is that the Commission is to have the same power as the Repatriation Commission to determine premises have the same function as a retirement village for the purposes of Part 11 of the Principles.

"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.

"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.

“social worker (general)” means a social worker who in the opinion of an employee of, or consultant to, the Department, has appropriate qualifications in social work and practises as a social worker.

“social worker (mental health)” means a social worker:

(a) who has been given a provider number in respect of being a social worker; and

(b) who, in the opinion of an employee of, or consultant to, the Department or the Department of Human Services, has appropriate qualifications in social work in the area of mental health and who practises as a social worker in the area of mental health.

“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) or a Home Care service (category C) to an entitled person.

“subsequent period of care”, in relation to the provision of care by an LMO to an entitled person, means a period of care that may be provided by the LMO after the expiry of a period of care that has already been provided by the LMO to the entitled person.

Note: a subsequent period of care must be approved by the LMO (see: 6A.3). A period of care by an LMO that is not a “subsequent period of care” would be the first period of care provided to a person under the Coordinated Veterans' Care Program (Program) and the first period of care provided to a person under the Program by a new LMO for the person i.e. where the person has changed LMOs.

“transition care” has the meaning it has in section 15.28 of the Flexible Care Subsidy Principles 1997.

Note: the Flexible Care Subsidy Principles 1997 can be found on COMLAW: http://www.comlaw.gov.au

“Tier 1 Hospital” means a hospital in the category described as Tier 1 in 2.1 of the MPPPs.

“Treatment Principles” means the legislative instrument entitled ‘Treatment Principles’ made by the Repatriation Commission under section 90 of the VEA.

"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 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 except where otherwise stated.

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;

(na) diabetes educator services specified in paragraph 7.6A.2;

(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 specified as requiring prior approval in or under Part 11;

(s) provision of visual aids to an entitled person by an optometrist (or optical product dispenser) that is not permitted under the arrangement between the optometrist (or optical product dispenser) and the Commission or the Department;

(t) repair of a rehabilitation appliance specified as requiring prior approval in or under Part 11;

(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;

(d) reasonable control over expenditure;

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

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

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.

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

(da) diabetes educator services, except where otherwise indicated in Principle 7.6A;

(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 provided by an optometrist to an entitled person in accordance with these Principles and the dispensing of optical products by an optometrist (or an optical product dispenser) to an entitled person except that, in the case of optical products, the optical products must be dispensed in accordance with these Principles and an arrangement between the optometrist (or optical product dispenser) and the Commission or the Department;

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 the Department of Human Services as a medicare benefit, 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 the Department of Human Services as a medicare benefit, a health insurance fund or another third party.

3.4.6 The Commission will not pay or reimburse the Medicare levy or the Medicare levy surcharge or pay or reimburse health insurance fund premiums.

Note: see the Medicare Levy Act 1986 for the Medicare levy and Medicare levy surcharge.

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 to an entitled person by a health care provider is as follows:

(1) for fees charged by:

(a) a chiropractor  the amount worked out under the DVA document entitled “Chiropractors Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the

Notes for Allied Health Providers (Section 1 General Information and Section 2(b)(Chiropractors));

(b) a dentist (Local Dental Officer)  the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dentists and Dental Specialists”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the

Notes for Allied Health Providers (Section 1 General Information and Section 2(c)(as section 2(c) affects dentists));

(c) a dental prosthetist  the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dental Prosthetists”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(c)(as section 2(c) affects dental prosthetists));

(d) a dental specialist  the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dentists and Dental Specialists”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(c)(as section 2(c) affects dental specialists, including as dentists));

(e) a diabetes educator  the amount worked out under the DVA document entitled “Diabetes Educators Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(d)(Diabetes Educators));

(f) a dietitian  the amount worked out under the DVA document entitled “Dietitians Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the

Notes for Allied Health Providers (Section 1 General Information and Section 2(e)(Dietitians));

(g) an exercise physiologist  the amount worked out under the DVA document entitled “Exercise Physiologists Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(f)(Exercise Physiologists));

(h) a LMO  the amount worked out under the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services”, in force on the date in Schedule 1, pursuant to the following parts of that document:

Chronic Pain Honorarium Fees;

Clinical Note Fees;

Compensation Consultation Fees;

Diagnostic Imaging Fee Schedule

Dose Administration Aid (DAA) Service Fees for GPs and LMOs;

Guide to the Assessment of Rates of Veterans' Pensions (GARP) Fee;

Kilometre Allowance;

Local Medical Officers (LMOs) Fee Schedule;

Medication Review Fees;

Pathology Fee Schedule;

Ready Reckoner for LMOs

Relative Value Guide Fee Schedule;

Repatriation Medical Fee Schedule;

on condition that the treatment was provided in accordance with the Principles and the Notes for Local Medical Officers;

(i) a medical specialist  the amount worked out under

the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services”, in force on the date in Schedule 1, pursuant to the following parts of that document:

Chronic Pain Honorarium Fees;

Clinical Note Fees;

Compensation Consultation Fees;

Diagnostic Imaging Fee Schedule

Dose Administration Aid (DAA) Service Fees for GPs and LMOs;

Guide to the Assessment of Rates of Veterans' Pensions (GARP) Fee;

Kilometre Allowance;

Medication Review Fees;

Pathology Fee Schedule;

Ready Reckoner for LMOs

Relative Value Guide Fee Schedule;

Repatriation Medical Fee Schedule;

on condition that the treatment was provided in accordance with the Principles;

(ia) a neuropsychologist — the amount worked out under the DVA document entitled “Neuropsychologists Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects a neuropsychologist));

(ja) an occupational therapist  the amount worked out under the DVA document entitled “Occupational Therapists Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles, as they affect an occupational therapist other than as an occupational therapist (mental health), and the

Notes for Allied Health Providers (Section 1 General Information and Section 2(g)(Occupational Therapists));

(j) an occupational therapist (mental health)  the amount worked out under the DVA document entitled “Occupational Therapists (Mental Health) Schedule of Fees”, in force on the date in Schedule 1, as the document relates to an occupational therapist (mental health), on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects occupational therapists (mental health));

(k) an optical dispenser of visual aids  the amount worked out under the DVA document entitled “Pricing Schedule for Visual Aids”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects optical dispensers));

(l) an optometrist  the amount worked out under the DVA document entitled “Optometrist Fees for Consultation”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects optometrists));

(m) an orthoptist  the amount worked out under the DVA document entitled “DVA Schedule of Fees Orthoptists”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles

and the Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects orthoptists));

(n) an osteopath  the amount worked out under the DVA document entitled “Osteopaths Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the

Notes for Allied Health Providers (Section 1 General Information and Section 2(i)(Osteopaths));

(o) an other GP  the amount worked out under the Notes for Local Medical Officers in respect of an other GP;

(p) a physiotherapist  the amount worked out under the DVA document entitled “Physiotherapists Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and section 2(j)(Physiotherapists));

(q) a podiatrist  the amount worked out under the DVA document entitled “Podiatrists Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the

Notes for Allied Health Providers (Section 1 General Information and Section 2(k)( Podiatrists));

(ra) a clinical psychologist  the amount worked out under the DVA document entitled “Clinical Psychologists Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects clinical psychologist (including as a psychologist));

(r) a psychologist  the amount worked out under the DVA document entitled “Psychologists Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the

Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects psychologists (other than as a clinical psychologist));

(sa) a social worker (general)  the amount worked out under the DVA document entitled “Social Workers Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects social workers (other than as a social worker (mental health));

(s) a social worker (mental health)  the amount worked out under the DVA document entitled “Social Workers (Mental Health) Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects social workers (mental health));

(u) a speech pathologist  the amount worked out under the DVA document entitled “Speech Pathologists Schedule of Fees”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(l)(Speech Pathologists));

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 care provider; and

(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 5 years (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, the Department of Human Services 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 5 years 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 the Department of Human Services, as a medicare benefit, or by a health insurance fund; or

(b) services where the cost is otherwise recoverable, wholly or partly, by way of a legal claim; 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 6A — COORDINATED VETERANS' CARE PROGRAM

6A.1 Outline

The “Coordinated Veterans' Care Program” (program) is an initiative that aims to improve the health of a class of entitled persons so they have fewer hospital admissions.

The entitled persons are Gold Card holders with complex care needs due to diagnosis of a particular chronic condition (set out in 6A.5).

The element of the program intended to reduce hospital admissions is external oversight of a person’s health regimen for a period of care of 3 months (carried over to consecutive periods of 3 months if the treatment is proving positive).

The oversight will be performed by a Local Medical Officer (LMO) and the LMO’s practice nurse (or a community nurse (via a DVA-contracted community nursing provider) or an aboriginal health worker, if more appropriate).

Essentially the LMO will prepare a comprehensive care plan (GPMP) for the entitled person and the LMO’s practice nurse (or a community nurse or aboriginal health worker) will co-ordinate health care services under the plan. The LMO will provide oversight throughout. In cases where an LMO is unable to obtain the services of a nurse or aboriginal health worker as a care co-ordinator, the LMO may provide that care co-ordination.

In addition to having their health care services overseen and co-ordinated, some entitled persons in the program who the LMO considers are socially isolated and would benefit from a service under a particular community care program aimed at providing the person with more social contact, may be referred by the LMO to a MHC assessment agency (an agency under the MRCA Home Care Program) for an assessment as to the suitability of the person for a social support service under that Program.

Accordingly, two main treatments are provided under the program:

LMO Care Leadership treatment
practice nurse/community nurse/aboriginal health worker/care co-ordination treatment

An ancillary treatment under the program is:

LMO referral for social support service assessment

The main treatments relate to the oversight and co-ordination of health care services under the entitled person’s comprehensive care plan (GPMP) and are in addition to existing treatments available to the entitled person under the Medicare Benefits Schedule and the MRCA Treatment Principles.

The ancillary treatment may be provided by an approved provider of MRCA Home Care services following a request for social support services from a MHC assessment agency. The LMO will have decided the person is socially isolated and that a social support service might prevent the person from being admitted or re-admitted to hospital. The MHC assessment agency will assess the person’s suitability for a social support service.

Note: an identical program for veterans exists under the Treatment Principles made under the Veterans’ Entitlements Act 1986.

6A.2 Treatments under the Coordinated Veterans' Care Program

6A.2.1 LMO Care Leadership treatment/LMO Home Care service (category C) Referral

6A.2.2 An LMO may, under the Coordinated Veterans' Care Program, provide:

(a) LMO Care Leadership treatment; and/or

(b) an LMO Home Care service (category C) Referral;

for an entitled person.

6A.2.3 Practice Nurse Care Co-ordination treatment

6A.2.4 A practice nurse may, under the Coordinated Veterans' Care Program, provide Practice Nurse Care Co-ordination treatment to an entitled person.

6A.2.5 Community Nurse Care Co-ordination treatment

6A.2.6 A DVA-contracted community nursing provider may, under the Coordinated Veterans' Care Program, provide Community Nurse Care Co-ordination treatment to an entitled person.

6A.2.7 Aboriginal Health Worker Care Co-ordination treatment

6A.2.8 An aboriginal health worker may, under the Coordinated Veterans' Care Program, provide Aboriginal Health Worker Care Co-ordination treatment to an entitled person.

6A.3 LMO Approval of Subsequent Period of Care

6A.3.1 Before any subsequent period of care of an entitled person by an LMO commences, being an LMO who is treating the person under the Coordinated Veterans' Care Program (Program), the LMO is to decide if the person’s continued participation in the Program would meet the aims of the Program (i.e. reduce hospitalisation of the person/avoid duplication of services/provide cost-effective treatment).

Note 1: the first period of care by an LMO commences on the date the LMO decides to admit the entitled person to the Program (admission date). Any following period of care by the same LMO is a subsequent period of care. The first period of care by an LMO may also occur where the LMO is a different LMO for the person. Any following period of care by the same LMO is a subsequent period of care.

Note 2: the period of care by an LMO is set out in the Notes for Coordinated Veterans' Care Program Providers and is a period of 3 months.

6A.3.2 For making the decision in 6A.3.1, the LMO is to:

(a) review the entitled person’s file maintained by the LMO and any other information the LMO considers relevant; and

(b) ascertain if the person is eligible for a subsequent period of care by the LMO.

Note: see 6A.6.2

6A.3.3. If the LMO decides the entitled person should continue to participate in the Program, because the person meets the aims of the Program and is eligible for a subsequent period of care by the LMO, the LMO is to:

(a) approve a subsequent period of care by the LMO of the entitled person before the period commences (approval);

(b) make a record of the approval (which may be in electronic form), containing the date of the approval;

(d) take any necessary steps to facilitate the provision of the subsequent period of care by the LMO to the entitled person.

6A.3.4. Where an LMO approves a subsequent period of care by the LMO for an entitled person, before the expiry of a current period of care by the LMO for the person, the subsequent period of care commences on the day following the day on which the current period of care expired.

6A.3.5. Where an LMO approves a subsequent period of care by the LMO for an entitled person (approval), after the expiry of a current period of care by the LMO for the person, the subsequent period of care commences on the date of the approval.

6A.3.6. If the LMO decides not to approve a subsequent period of care by the LMO of the entitled person, because the person does not meet the aims of the Program or is ineligible for a subsequent period of care by the LMO, the LMO is to:

(a) notify (including by telephone) any DVA-contracted community nursing provider who may have co-ordinated care for the entitled person under the Program immediately before the potential subsequent period of care by the LMO, of the decision;

(b) if the entitled person was receiving a Home Care service (category C) immediately before the potential subsequent period of care by the LMO, notify (including by telephone) the MHC assessment agency for the person, of the decision;

6A.4 Commission Financial Responsibility for Treatment under the Coordinated Veterans' Care Program

6A.4.1 The Commission will accept financial responsibility for:

(a) LMO Care Leadership treatment;

(b) Practice Nurse Care Co-ordination treatment;

(d) Aboriginal Health Worker Care Co-ordination treatment;

provided to an entitled person, during a period of care of the person by the LMO, the practice nurse, the community nurse or the aboriginal health worker, as the case may be, if the treatment is provided:

(a) in accordance with the Principles and the Notes for Coordinated Veterans' Care Program Providers; and

(b) during a period of care provided to the entitled person by the LMO under the Coordinated Veterans' Care Program (Program).

6A.4.2 The financial amounts the Department will pay for:

(a) LMO Care Leadership treatment, Practice Nurse Care Co-ordination treatment and Aboriginal Health Worker Care Co-ordination treatment — are set out in the DVA document entitled: “Department of Veterans’ Affairs Fee Schedules for Medical Services”, in force on the date in Schedule 1;

(b) Community Nurse Care Co-ordination treatment — are set out in the DVA document entitled: “Australian Government Department of Veterans’ Affairs Classification System and Schedule of Item Numbers and Fees — Community Nursing Services”, in force on the date in Schedule 1.

Note: the Department of Human Services will pay fees on behalf of the Department under a Services Agreement.

6A.4.3 Subject to 6A.4.4, the Commission is only to accept financial responsibility for a period of care provided to an entitled person by an LMO, practice nurse, community nurse or aboriginal health worker under the Coordinated Veterans' Care Program (Program) if any previous period of care provided by, respectively, an LMO, practice nurse, community nurse or aboriginal health worker under the Program in respect of the entitled person has expired.

Note: Under the Coordinated Veterans' Care Program a period of care provided by an LMO, practice nurse, community nurse or aboriginal health worker must be in respect of the Coordinated Veterans' Care Program treatment the health care provider may provide under the Program.

6A.4.4 A practice nurse or community nurse (collectively called “nurse 2”) may provide a period of care comprised of, respectively, Practice Nurse Care Co-ordination treatment or Community Nurse Care Co-ordination treatment, to an entitled person under the Program, where a period of care comprised of, respectively, Practice Nurse Care Co-ordination treatment or Community Nurse Care Co-ordination treatment being provided in respect of the entitled person by another practice nurse or community nurse, as the case requires, (collectively called “nurse 1”) under the Program has not expired — if the LMO or DVA-contracted community nursing provider, as the case requires, for nurse 2, has obtained prior approval.

Note 1: Where a period of care provided by nurse 2 and nurse 1 overlaps, and prior approval has been obtained for nurse 2’s period of care, the Commission may accept financial responsibility for the two simultaneous periods of care.

Note 2: “prior approval” is defined in 1.4.1 and 3.2.2 is also relevant. The grant of prior approval is discretionary and for 6A.4.4 will be considered on a case-by-case basis.

6A.4.5 The payment of a fee for Practice Nurse Care Co-ordination treatment and Aboriginal Health Worker Care Co-ordination treatment will be made by the Department to the LMO who employed or engaged the practice nurse or aboriginal health worker, as the case may be, at the time the treatment was provided.

6A.4.6 The payment of a fee for Community Nurse Care Co-ordination treatment provided by a community nurse will be made by the Department to the DVA-contracted community nursing provider who employed or engaged the nurse at the time the treatment was provided.

6A.5 Entitlement to Participation in the Coordinated Veterans' Care Program and to Coordinated Veterans' Care Program Treatment under the program

6A.5.1 Subject to 6A.3 and 6A.6, an entitled person is entitled to participation in the Coordinated Veterans' Care Program (program) and to Coordinated Veterans' Care Program treatment under the program if:

(1) in the opinion of an LMO treating the person:

(a) the entitled person has one or more of the following conditions:

(i) congestive heart failure; or

(ii) coronary artery disease; or

(iii) pneumonia; or

(iv) chronic obstructive pulmonary disease; or

(v) diabetes; or

(vi) some other chronic condition; and

(b) the condition in (1)(a) has resulted in the person being admitted frequently to hospital or could reasonably result in the person being admitted frequently to hospital; and

(i) one or more of:

(aa) multiple co-morbidities that complicate the treatment regimen for the person;

(bb) the person’s condition is unstable with a high risk of acute exacerbation;

(cc) the condition is contributed to by frailty, age and/or social isolation factors;

(dd) there are limitations in self management and monitoring;

and:

(ii) needs which require a treatment regimen that involves one or more of the following complexities of ongoing care:

(aa) multiple care providers;

(bb) complex medication regimen;

(cc) frequent monitoring and review;

(dd) support with self management and self monitoring.

(2) the person is eligible for treatment under the Act for any injury suffered, or disease contracted, by the person (i.e. person has been granted a Gold Card); and

(3) the person is an Australian resident and living in Australia; and

(4) the person has consented to participation in the program and the admitting LMO has recorded the consent (which may be an electronic record); and

Note: under the Notes for Coordinated Veterans' Care Program Providers the LMO is to store the consent.

(5) the LMO treating the person has prepared, in consultation with the person, a comprehensive care plan (GPMP); and

(6) the LMO admits the person to the program by making a decision to that effect and keeping a record of it.

6A.6 Ineligibility for participation in the Coordinated Veterans' Care Program (program) and for Coordinated Veterans' Care Program Treatment and LMO Home Care service (category C) Referral under the program

6A.6.1 An entitled person is ineligible to be admitted to the Coordinated Veterans' Care Program (Program) by an LMO for the person if any one of the following applies to the person:

(a) the person is receiving residential care; or

Note: receiving residential care (respite) does not disentitle a person to participation in the program.

(b) the person has been diagnosed by a medical practitioner as having a condition that, in the opinion of the LMO, would be likely to be terminal within 12 months after the person is admitted to the program, if the person were to be admitted; or

(i) “Coordinated Care for Patients with Diabetes” (including as a pilot program); or

(ii) “Extended Aged Care at Home program”; or

(iii) “Community Aged Care Program”; or

(iv) “Transition Care”;

or in a program provided by that Department that is essentially the same as one in (i) –(iv) but with a different name.

6A.6.2 An entitled person is not eligible for a subsequent period of care by an LMO under the Program if immediately before the commencement of the potential period of care the matters in (a) or (c) of 6A.6.1 apply to the person.

Note: the period of a period of care by an LMO is set out in the Notes for Coordinated Veterans' Care Program Providers and is a period of 3 months.

6A.7 Date of Admission for Participation in the Coordinated Veterans' Care Program

6A.7.1 Subject to 6A.3 and 6A.6, treatment of an entitled person under the Coordinated Veterans' Care Program (program) commences on the admission day for the person and continues throughout any period of care provided by an LMO to the entitled person under the program.

Note: treatment under the program provided by a practice nurse, community nurse or aboriginal health worker can only occur during a period of care provided by an LMO under the program.

6A.8 LMO Home Care service (category C) Referral

6A.8.1 An LMO treating an entitled person under the Coordinated Veterans' Care Program may decide the person would benefit from a Home Care service (category C) and may refer the person to a MHC assessment agency for an assessment as to the person’s suitability for the service and, depending on the outcome, the agency may allocate responsibility for providing the Home Care service (category C) to an approved provider. The referral is treatment known as: LMO Home Care service (category C) Referral.

Note: for the purposes of 7.3A.1(1)(a)(iii) the referral to a MHC assessment agency is also taken to be a referral to the Commission.

6A.8.2 The LMO may provide an LMO Home Care service (category C) Referral for an entitled person if:

(1) the person is admitted to the Coordinated Veterans' Care Program; and

(2) in the opinion of the LMO:

(a) the person has a limited or inadequate social support network and could reasonably be at risk of hospitalisation for a condition in 6A.5.1(1)(a) because of that social situation; and

(b) the risk of the person being hospitalised for a condition in 6A.5.1(1)(a) may be significantly reduced if the person received a Home Care service (category C).

Note: a referral must comply with the requirements in the definition of Home Care service (category C) Referral.

6A.9 Procedures under the Coordinated Veterans' Care Program.

6A.9.1 An LMO may medically assess an entitled person the LMO is treating to determine if the person would benefit from participation in the Coordinated Veterans' Care Program (program).

6A.9.2 If the LMO decides the entitled person would benefit from participation in the program, and the person is entitled to participate in the program, then the LMO is to inform the entitled person that the person’s participation in the program is conditional upon the person consenting to personal information about the person that is relevant to the person’s treatment under the program being provided to bodies such as:

the Department;
Contractors to the Department who provide services related to the administration of the Program or who would provide a Home Care service (category C) (social support service) to the person;
the Department of Human Services (which pays treatment costs for the Department);
health care providers associated with the person’s treatment under the program.

The LMO is to obtain the person’s consent, if the person is to participate in the program, and record it and store it in a readily retrievable form.

Note: consent may be recorded and stored in electronic form.

6A.9.3 Once an entitled person’s consent is obtained the LMO is to admit the person to the program. This takes the form of the LMO recording in writing (including in electronic form) that the person has been admitted to the program. Participation in the program commences on and from the admission date.

6A.9.4 The LMO is to prepare, in consultation with the person, a comprehensive care plan for the person (GPMP).

6A.9.5 A practice nurse (nurse working for the LMO) or, if appropriate, a community nurse (nurse working for a DVA-contracted community nursing provider) or an aboriginal health worker (working for the LMO) will co-ordinate care services under the GPMP (care co-ordinator). The LMO may need to refer co-ordination of the GPMP to a DVA-contracted community nursing provider if, for example, the LMO does not employ a practice nurse. In some cases the LMO may not be able to secure the services of a care co-ordinator and may need to provide the service themselves but the main role of the LMO is to provide oversight of the care co-ordination under the GPMP.

6A.9.6 Part of the monitoring mechanism for the program involves the LMO assessing the progress an entitled person is making (progress assessment). This is to occur toward the end of a period of care by the LMO and before the LMO provides a further period of care to the person. More details of the procedure is at 6A.3. A progress assessment is not a prerequisite to the commencement of an initial period of care.

6A.9.7 If the LMO decides that the entitled person is socially isolated and that because of that situation the person could be reasonably at risk of being hospitalised for a condition in 6A.5.1(1)(a) and that the risk of hospitalisation may be significantly reduced by the provision of a Home Care service (category C) to the person — then the LMO may refer the person to a MHC assessment agency for an assessment as to the person’s suitability for the service. The referral is called: LMO Home Care service (category C) Referral.

6A.9.8 The MHC assessment agency is to assess a person pursuant to a LMO Home Care service (category C) Referral and is to determine if the person is suitable for a Home Care service (category C), using the standard assessment process that the agency applies to all assessments for services under the MRCA Home Care Program, and is to determine the type, duration and frequency of any Home Care service (category C) to be provided to a person.

6A.9.9 When providing treatment under the Coordinated Veterans' Care Program an LMO, a practice nurse, a DVA-contracted community nursing provider (for a community nurse), and an aboriginal health worker are to comply with the requirements in these Principles and any requirements in the Notes for Coordinated Veterans' Care Program Providers that relate to them.

PART 7 — TREATMENT GENERALLY FROM OTHER HEALTH PROVIDERS
7.1 Prior approval and financial responsibility for health services

7.1.1 Except where otherwise provided in:

(1) the Principles;

(2) Notes for Allied Health Providers; or

(3) a Fee Schedule;

in respect of a particular treatment, the Commission is not to accept financial responsibility for the treatment under this Part unless the Commission’s prior approval for the treatment has been obtained by the entitled person or entitled person’s health care provider.

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

(aa) diabetes educator services;

(b) dietetics;

(d) community nursing;

(dd) exercise physiology;

(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.

7.1A.1 In order for the Commission to accept financial responsibility for treatment provided to an entitled person by a health care provider in an item (denoted by a number) in Column A below, the treatment must have been provided in accordance with the section of the Notes for Allied Health Providers for that item in Column B below, as that section relates to the health care provider:

Column A Column B

		Notes for Allied Health Providers
	Provider Type	General section	Provider specific section
1	Chiropractors	Section 1 - General Information	Section 2(b) – Chiropractors
2	Clinical Psychologists	“	Section 2(a) – Allied Mental Health Care Providers
3	Dentists, Dental Specialists & Dental Prosthetists	“	Section 2(c) – Dentists, Dental Specialists and Dental Prosthetists
4	Diabetes Educators	“	Section 2(d) - Diabetes Educators
5	Dietitians	“	Section 2(e) – Dietitians
6	Exercise Physiologists	“	Section 2(f) – Exercise Physiologists
7	Neuropsychologists	“	Section 2(a) – Allied Mental Health Care Providers
8	Occupational Therapists	“	Section 2(g) – Occupational Therapists
9	Occupational Therapists – Mental Health	“	Section 2(a) – Allied Mental Health Care Providers
10	Optometrists, Orthoptists & Optical Dispensers	“	Section 2(h) - Optometrists, Orthoptists & Optical Dispensers
11	Osteopaths	“	Section 2(i) – Osteopaths
12	Physiotherapists	“	Section 2(j) – Physiotherapists
13	Podiatrists	“	Section 2(k) – Podiatrists
14	Psychologists	“	Section 2(a) – Allied Mental Health Care Providers
15	Social Workers	“	Section 2(a) – Allied Mental Health Care Providers
16	Social Workers – Mental Health	“	Section 2(a) – Allied Mental Health Care Providers
17	Speech Pathologists	“	Section 2(l) – Speech Pathologists

7.1B Disqualified Health Care Providers

7.1B.1 The Commission is not to accept financial responsibility for the cost of a service provided to an entitled person by, or on behalf of, a health care provider if, at the time the service was provided, a medicare benefit would not have been payable in respect of the service under section 19B of the Health Insurance Act 1973 (in force from time to time) if the health care provider had provided the service as a practitioner under that Act.

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 DVA-contracted community nursing providers is dealt with in the arrangements between the Commission and DVA-contracted community nursing provider.

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 DVA-contracted community nursing providers is dealt with in the arrangements between the Commission and the DVA-contracted community nursing provider.

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 DVA-contracted community nursing provider is dealt with in the arrangements between the Commission and the DVA-contracted community nursing provider.

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 DVA-contracted 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 DVA-contracted community nursing provider to whom an entitled person can be referred under paragraph 7.3.3(a).

(b) a DVA-contracted 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 DVA-contracted community nursing provider shall be provided to the Department upon request by the Department to the DVA-contracted 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 DVA-contracted community nursing provider is to be made only to a DVA-contracted 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 DVA-contracted 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 DVA-contracted 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:

(a) examine the circumstances of an entitled person and assess the suitability of the person for:

(i) a Home Care service (category A); or

(ii) a Home Care service (category B); or

(iii) pursuant to a LMO Home Care service (category C) Referral, a Home Care service (category C).

Note: the Commission has delegated its assessment power to a contractor known as a VHC assessment agency.

(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 Outcome of Assessment

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

(2) Where under 7.3A.1(1) the Commission decides that an entitled person is suitable for a relevant service, it shall:

(a) determine the type, duration and frequency of the service;

(b) in the case of a Home Care service (category A) or a Home Care service (category C) — allocate responsibility for providing the service to an appropriate approved provider; and

Note (1): in practice the Commission may delegate its power to assess a person’s suitability for a service to contractors (called MHC assessment agency).

Note (2): The Commission may also delegate its power to allocate the task of providing any “category A or C service” to contractors (called a MHC assessment agency).

Note (3): The Commission may delegate its power to provide a Home Care service (category B) to a contractor (e.g. an instrumentality of a State or Territory).

Note (4): Contractors may, in turn, sub-contract the responsibility to provide a relevant service.

7.3A.4A An approved provider may provide a Home Care service (category A), a Home Care service (category B) or a Home Care service (category C) to an entitled person.

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 is suitable for 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.6B The Commission may accept financial responsibility for the provision of a Home Care service (category C) to an entitled person by an approved provider, for a period of care provided by an LMO to the entitled person under the Coordinated Veterans' Care Program, if:

(1) the approved provider has an arrangement with the Commission or the Department to provide a Home Care service (category A) or Home Care service (category B) to an entitled person; and

(2) the service has been requested for the person by a MHC assessment agency pursuant to a LMO Home Care service (category C) Referral and pursuant to an assessment by the agency of the person’s suitability for the service; and

(3) the service is in accordance with the request from the MHC assessment agency; and

Note: it will be the MHC assessment agency’s responsibility to inform the approved provider of the terms on which the service is to be provided e.g. frequency of service.

(4) the service is in accordance with any requirements in the Notes for Coordinated Veterans' Care Program Providers (Notes) that relate to an approved provider delivering a Home Care service (category C) to an entitled person; and

(5) the entitled person is otherwise entitled to the service and is not, at the time of the service, receiving residential care; and

(6) the service is not essentially the same as a Home Care service (category A) or Home Care service (category B)

the person is entitled to receive.

7.3A.7 For the purposes of the Principles, an approved provider is deemed to be a health care 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) or Home Care service (category C) 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) or Home Care service (category C) 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) or Home Care service (category C).

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) or Home Care service (category C).

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) or Home Care service (category C) 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) or Home Care service (category C) 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) or Home Care service (category C) 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) or a Home Care service (category C) 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) or Home Care service (category C):

(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 or Home Care service (category C) 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:

(a) the provision of a Home Care service (category A) to an entitled person by an approved provider;

(b) the provision of a Home Care service (category B) to an

entitled person by an approved provider; or

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  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  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  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  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  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  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 may accept financial responsibility for optometrical services provided by an optometrist (with a current provider number) to an entitled person in accordance with these Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects optometrists)).

7.4.2 The Commission may accept financial responsibility for optometrical products provided by an optical dispenser (who may be an optometrist) to an entitled person if those products have been provided in accordance with:

(a) the Principles; and

(b) the Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects optometrists and optical dispensers)); and

7.4.3 Optometrical products are those referred to in the DVA document entitled “Pricing Schedule for Visual Aids”, in force on the date in Schedule 1.

Note:the Pricing Schedule for Visual Aids is available at any office of the Department.

7.4.4 An optometrist or an optical dispenser may render the account for services provided to an entitled person either to the Department or to the Department of Human Services under the direct billing arrangements.

7.4.5 When an optometrist or an optical dispenser direct bills the Department of Human Services 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 who has 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

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 who has 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;

(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 who has a provider number, with or without sterilisation of the matrix, only if prior approval has been obtained.

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

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

7.6A Diabetes Educator services

7.6A.1 Subject to paragraph 7.6A.2 the Commission may accept financial responsibility for diabetes educator services provided to an entitled person with diabetes where:

(a) a referer, being a LMO, other GP, medical specialist, discharge planner, a treating doctor in a hospital or another diabetes educator with a current referral, refers the entitled person to a diabetes educator for diabetes educator services; and

(b) except where the referer is of the opinion that the entitled person suffers from chronic diabetes that needs ongoing treatment, twelve months has not elapsed from the date of the referral or, where an entitled person is referred by a diabetes educator to another diabetes educator, twelve months has not elapsed from the date of the original referral; and

7.6A.2 Prior approval is required for diabetes educator services where:

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

(b) those services are to be provided to an entitled person in a public hospital.

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 who has 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;

(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.

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

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:

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, CARE AT HOME PACKAGES AND TRANSITION CARE CO-PAYMENT

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.

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

10.2.1 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.

10.3 Residential care (respite) arrangements

10.3.1 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.

10.3.2 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

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 year — between 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.

10.3.4 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.

10.3.5 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.

10.3.6 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).

10.3.7 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.

10.3.8 (1) For the purposes of paragraphs 10.3.1 to 10.3.7 (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

10.3.9 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.

10.3.10 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.

10.4 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 10.3.1 and to Respite Care under the MRCA Home Care Program.

Part D - CARE AT HOME PACKAGES

10.5 The Commission may accept financial responsibility for a Community Aged Care Package or Extended Aged Care at Home Package for a former prisoner of war, or an entitled member awarded the Victoria Cross for Australia (VC recipient), who is receiving (or who has received) such a care package.

10.6 Financial responsibility is limited to responsibility for the amount (co-payment) the former prisoner of war or VC recipient paid, or is to pay, pursuant to an agreement with the provider of the care package — to the extent the co-payment does not exceed any limit under:

(a) the Aged Care Act 1997;

(b) instruments under the Aged Care Act 1997; or

(c) any agreement between the provider of the care and the Secretary of the Department that administers the Aged Care Act 1997;

and financial responsibility does not include responsibility for the cost of the care package that would otherwise be subsidised under the Aged Care Act 1997.

10.7 In deciding whether to accept financial responsibility for a Community Aged Care Package or Extended Aged Care at Home Package provided to a former prisoner of war or VC recipient the Commission should take into account:

(a) whether the care was provided in accordance with the relevant provisions of the Aged Care Act 1997 and the relevant instruments thereunder;

(b) whether the care complies with the requirements of any agreement between the provider of the care and the Secretary of the Department that administers the Aged Care Act 1997; and

(c) whether the care essentially duplicates treatment the former prisoner of war or VC recipient is receiving under other provisions of the Principles (double-dipping).

10.8 Billing

10.8.1 The provider of a Community Aged Care Package or Extended Aged Care at Home Package should bill Medicare Australia rather than the former prisoner of war or VC recipient (client) but if the client is billed, the Commission may, subject to paragraph 10.6, accept financial liability for the amount.

Part E – TRANSITION CARE CO-PAYMENT

10.9 Financial Responsibility for Co-Payment

10.9.1 Subject to 10.9.2 the Commission may accept financial responsibility for transition care (care) provided by an approved provider to:

(a) an entitled member who is former prisoner of war (POW); or

(b) an entitled member awarded the Victoria Cross for Australia (VC recipient);

on condition that the care is provided on a day in respect of which flexible care subsidy is payable for the care under the Flexible Care Subsidy Principles 1997.

Note: as at December 2010 the maximum number of days for which flexible care subsidy was payable for transition care was 126 days.

10.9.2 For 10.9.1, financial responsibility is limited to responsibility for the amount (co-payment) the POW or VC recipient paid, or is to pay, to an approved provider — to the extent:

(a) the co-payment does not exceed the amount the approved provider is permitted to charge the POW or VC recipient under section 56-3 of the Aged Care Act 1997; and

(b) the co-payment does not exceed the amount the approved provider is permitted to charge the POW or VC recipient under any agreement between the Secretary of the Department that administers the Aged Care Act 1997 and the approved provider pursuant to section 15.33 of the Flexible Care Subsidy Principles 1997.

10.9.3 In deciding whether to accept financial responsibility for transition care (care) provided to a POW or VC recipient the Commission should take into account:

(a) whether the care was provided in accordance with the relevant provisions of the Aged Care Act 1997 and the relevant instruments thereunder;

Note 1: Part 3.3 of Chapter 3 of the Aged Care Act 1997 deals with transition care (flexible care)

Note 2: The Approval of Care Recipients Principles 1997, the Flexible Care Subsidy Principles 1997 and the User Rights Principles 1997 are relevant to transition care (flexible care).

(b) whether the care complies with:

(i) any agreement between the approved provider of the care and the Secretary of the Department that administers the Aged Care Act 1997 — under the Aged Care Act 1997 and under 15.33 of the Flexible Care Subsidy Principles 1997; and

(c) whether, if there is an agreement mentioned in (b)(i) and the agreement (Provider/Secretary Agreement) sets out requirements for agreements (client agreement) between an approved provider and a recipient of flexible care or flexible care that is transition care:

(i) the client agreement satisfies any requirements in respect of it in the Provider/Secretary Agreement; and

(ii) the provision of care complies with the client agreement.

(d) whether the care essentially duplicates treatment the POW or VC recipient is receiving under other provisions of the Principles (double-dipping).

10.10 Billing

10.10.1 An approved provider should bill the Department of Human Services for the co-payment for transition care, rather than the POW or VC recipient (client) but if the client is billed, the Commission may, subject to 10.9.2 and 10.9.3, accept financial responsibility for the amount.

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.

Note: the RAP National Schedule of Equipment and the Rehabilitation Appliances Program (RAP) National Guidelines are DVA documents that provide guidance to the Commission and to prescribers and suppliers in relation to the provision of surgical aids and appliances for self-help and rehabilitation to entitled persons.

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

(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

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.

Note: an example where the Commission could request the return of a rehabilitation appliance is where it cannot be accommodated in an institution.

11.2A Prior Approval

11.2A.1 If under this Part or under the DVA documents entitled, respectively, the “RAP National Schedule of Equipment” in force on the date in Schedule 1 and the "Rehabilitation Appliances Program (RAP) National Guidelines" in force on the date in Schedule 1, the Commission's prior approval is required for the supply of a rehabilitation appliance to an entitled person or the alteration to, replacement or repair of a rehabilitation appliance, then the Commission is not to accept financial liability for the supply, alteration, replacement or repair, as the case may be, unless it has granted that prior approval.

Note: in granting prior approval the Commission must consider the matters in paragraph 3.2.2.

11.2A.2 A grant of prior approval must be recorded in writing by the Department within 7 days after it has been made.

11.2A.3 The record may be maintained in electronic form and must be stored by the Department for a period of at least 12 months commencing on the 8th day after the grant of prior approval was made.

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

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 Subject to 11.3.6A and 11.3.7, the Commission will not approve the supply of a rehabilitation appliance to an entitled person who is in an institution or who has entered a Commonwealth, State or Territory program if the Commission is satisfied that:

(a) for an institution, the appliance should be supplied by the owner or operator of the institution because:

(i) any Commonwealth, State or Territory legislation under which the institution (or owner or operator) is registered, licensed or otherwise authorised enables the appliance to be supplied; or

(ii) due to charges made by or subsidies received by the owner or operator of the institution under Commonwealth, State or Territory legislation, it is fair for the owner or operator of the institution to bear the cost of supplying the appliance; or

Note: the DVA document known as “RAP Business Rules” provides a guide to decision making in respect of the supply of appliances and is contained in the RAP Schedule of Equipment at:

http://www.dva.gov.au/service_providers/rap/Pages/Schedule_Guidelines.aspx

(iii) installing the appliance would involve an alteration to the structure of part of the institution; or

(iv) it is otherwise appropriate for the appliance to be supplied by the owner or operator.

Note (1): “institution” includes a retirement village, premises the Commission considers have similar functions to a retirement village and premises known as a self-care unit.

Note (2): the DVA document known as “RAP Business Rules” provides a guide to decision making in respect of the supply of appliances and is contained in the RAP Schedule of Equipment at:

http://www.dva.gov.au/service_providers/rap/Pages/Schedule_Guidelines.aspx

(b) for an institution, where the appliance is a hand rail, ramp, non-slip surface or similar appliance, the appliance should be supplied by the entitled person or the owner or operator of the institution because the entitled person should have known, by reason of the person’s state of health or frailty at the time the person arranged to enter the institution, that such an appliance would have been likely to have been needed by the person upon being admitted to the institution or a short time thereafter.

Note (1): “institution” includes a retirement village, premises the Commission considers have similar functions to a retirement village and premises known as a self-care unit.

Note (2): The policy is that entitled persons entering institutions should ensure the institution caters to their needs before they take up residence.

Note (3): A guide to a “short time” is a period within 6 months after entering the institution.

Note (4): the DVA document known as “RAP Business Rules” provides a guide to decision making in respect of the supply of appliances and is contained in the RAP Schedule of Equipment at:

http://www.dva.gov.au/service_providers/rap/Pages/Schedule_Guidelines.aspx

(i) the Commonwealth financially contributed to the program, if the case; or

(ii) the program’s budget appears sufficient to reasonably absorb the cost of the appliance; or

(iii) the Department is under a short-term financial constraint; or

(iii) it is otherwise appropriate for the appliance to be supplied under the program.

Note: the DVA document known as “RAP Business Rules” provides a guide to decision making in respect of the supply of appliances and is contained in the RAP Schedule of Equipment at:

http://www.dva.gov.au/service_providers/rap/Pages/Schedule_Guidelines.aspx

11.3.6A The Commission will approve the supply of a rehabilitation appliance to an entitled person in an institution or participating in a Commonwealth, State or Territory program, if:

(a) the Commission approved the appliance for the person before the person entered the institution or the program and that approval has not been revoked; and

(b) for a person in an institution, any alteration to the structure of part of the institution necessary to install or attach the appliance satisfies the requirements in (a) and (b) of 11.3.7; and

Note: (a) and (b) deal with compliance with relevant laws and approval by owner of property to installation/attachment together with an undertaking by the owner not to seek compensation if the appliance is removed.

rehabilitation appliance.

Note (1): “institution” includes a retirement village, premises the Commission considers have similar functions to a retirement village and premises known as a self-care unit.

Note (2): 11.3.6A is relevant in relation to the maintenance or repair of the appliance. Generally, only an approved appliance may be maintained or repaired at Commission expense.

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 may accept financial liability for visual aids dispensed by an optical dispenser (who may be an optometrist) to an entitled person on the prescription of an ophthalmologist or an optometrist (with a current provider number) where the visual aids have been provided in accordance with:

(a) the Principles; and

(b) Notes for Allied Health Providers (Section 1 General Information and Section 2(h)(as section 2(h) affects optometrists and optical dispensers)); and

11.4.2 Visual aids may be prescribed from the DVA document entitled “Pricing Schedule for Visual Aids”, in force on the date in Schedule 1.

11.4.3 The Commission’s prior approval is required for the prescription of items not listed in the DVA document entitled “Pricing Schedule for Visual Aids”, in force on the date in Schedule 1, 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 DVA document entitled “Pricing Schedule for Visual Aids”, in force on the date in Schedule 1, 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.

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

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

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 The Commission may assist in providing aids and appliances for accident prevention and personal safety for an entitled person by approving, only once in any period of 12 months, financial assistance towards the cost of such aids or appliances to a maximum amount of $200 (maximum amount) — increased annually (if the following formula results in an increase) on 1 January by an amount worked out in accordance with the following formula:

maximum amount (including as indexed) x the movement (expressed as a percentage) in the Wage Cost Index 5 for the previous financial year (as advised to the Department by the Australian Government Treasury), rounded to the nearest dollar = increase.

11.9.1A For the purposes of paragraph 11.9.1:

(a) a period of 12 months commences on the date the Commission approves financial assistance; and

(b) the Commission is not to approve financial assistance for an entitled person if 12 months has not elapsed from and including the date of any previous approval.

11.9.1B Where the Commission approves financial assistance under paragraph 11.9.1 of the Principles before the commencement of the MRCA Treatment Principles (HomeFront - Frequency of Subsidy) Instrument 2009 (commencement date), and on the commencement date a period of 12 months had not expired from and including the date of that approval, the approval is taken to have been granted under the Principles as amended by the MRCA Treatment Principles (HomeFront - Frequency of Subsidy) Instrument 2009 and the period of 12 months commences on the date of the approval.

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

(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 will not accept financial responsibility, either partly or wholly, for the purchase, supply, or installation of an aid or appliance for accident prevention and personal safety in respect of an entitled person who is in an institution or who has entered a Commonwealth, State or Territory program if, had the appliance been a rehabilitation appliance considered for supply under 11.3.6, the Commission would not, under 11.3.6, have approved its supply in respect of the person.

Note (1): “institution” includes a retirement village, premises the Commission considers have similar functions to a retirement village and premises known as a self-care unit.

Note (2): the intention is that only the “rehabilitation appliance provisions” in respect of institutions/programs apply to “accident prevention and personal safety appliances” in institutions or under programs, not that any other rehabilitation appliance provision applies to accident prevention and personal safety appliances in institutions or under programs.

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.

5.3 Entitlement

PART 6A — COORDINATED VETERANS' CARE PROGRAM

PART 7 — TREATMENT GENERALLY FROM OTHER HEALTH PROVIDERS 7.1 Prior approval and financial responsibility for health services

7.6 Podiatry

7.7 Chiropractic and osteopathic services

9.2 Financial Responsibility For Treatment In Hospital

12.2 Treatment under Medicare Program

PART 7 — TREATMENT GENERALLY FROM OTHER HEALTH PROVIDERS
7.1 Prior approval and financial responsibility for health services