MRCA Treatment Principles (No. MRCC 53/2013)

Link to law: https://www.comlaw.gov.au/Details/F2013L02016

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Australian Government
 
Military Rehabilitation and Compensation Act 2004
 
MRCA treatment principles
 
Instrument 2013 No. MRCC 53
 
 
I, Michael Ronaldson, Minister for Veterans’ Affairs, pursuant to section 286(3) of the Military Rehabilitation and Compensation Act 2004, approve this instrument made by the Military Rehabilitation and Compensation Commission.
Dated this       26th     day of              November       2013
Michael Ronaldson……………………….............................................
MICHAEL RONALDSON
 
The Military Rehabilitation and Compensation Commission:
(a) pursuant to section 286(2) of the Military Rehabilitation and Compensation Act 2004 (the Act) revokes the instrument made under section 286(1) of the Act known as the MRCA Treatment Principles (Instrument 2004 No. M21); and
(b) pursuant to section 286(1) of the Act hereby determines the places at which, the circumstances in which, and the conditions subject to which, a particular kind or class of treatment may be provided under Part 3 of Chapter 6 of the Act; and determines the matters in paragraphs 286(1)(d), (e) (f) and (g) of the Act.
Dated this              13th        day of                    November             2013
 
The Seal of the                                                                     )
Military Rehabilitation                                                       )
and Compensation Commission                                   )SEAL
was affixed hereto in the                                                   )
presence of:                                                                          )
Simon Lewis………………Shane Carmody………………Major General Mark Kelly………....
SIMON LEWIS                 SHANE CARMODY              Major General Mark Kelly
                                                                                                                                                AO DSC
CHAIR                                     MEMBER                           MEMBER
                                                                  
Kylie Emery………………………                    …..........Rear Admiral Robyn Walker AM, RAN
Ms Kylie Emery                                   Rear Admiral robyn walker am, ran
ACTING MEMBER                                   ACTING MEMBER
 
 
Table of provisions
 
 
PART 1 — INTRODUCTION/COMMENCEMENT
1.2          Application of MRCA Private Patient Principles
1.3          Delegation
1.4          Interpretation
PART 2 — ENTITLEMENT TO TREATMENT
2.1          Treatment for entitled persons in Australia
2.2          Treatment for entitled persons residing or travelling overseas
2.2.8       No Overseas MRCA Home Care or Homefront
2.3          Treatment of associated non-service injury or disease injuries or diseases
2.6          Referrals by Vietnam Veterans' Counselling Service
2.7A       Centre for Military and Veterans' Health Treatment
2.7B       Australian Centre for Posttraumatic Mental Health Treatment
2.8          Loss of eligibility for treatment
PART 3 — COMMISSION APPROVAL FOR TREATMENT
3.1          Approval for treatment
3.2          Circumstances in which prior approval is required
3.3          Circumstances in which prior approval may not be required
3.4          Other retrospective approval
3.5          Financial responsibility
PART 4 — MEDICAL PRACTITIONER SERVICES
4.1          Medical Practitioner Services
4.2          Providers of services
4.3          Financial responsibility
4.3A       Disqualified Medical Practitioners
4.4          Referrals by Local Medical Officer or other GPs
4.5          Referrals by medical specialists
4.7          Referrals: prior approval
4.8          Other matters
PART 5 — DENTAL TREATMENT
5.1          Providers of services
5.2          Financial responsibility
5.2A       Disqualified Dental Practitioners
5.3          Entitlement
5.4          Emergency dental treatment
5.5          Orthodontic treatment for children
5.6          General anaesthesia
5.7          Prescribing of pharmaceutical benefits by dentists
5.8          Other dental services
PART 6 — PHARMACEUTICAL BENEFITS
6.1          MRCA Pharmaceutical Benefits Scheme
6.2          Entitlement under the MRCA Pharmaceutical Benefits Scheme
PART 6A — COORDINATED VETERANS' CARE PROGRAM
6A.1       Outline
6A.2       Treatments under the Coordinated Veterans' Care Program
6A.3       LMO Approval of Subsequent Period of Care
6A.4       Commission Financial Responsibility for Treatment under the Coordinated Veterans' Care Program
6A.5       Entitlement to Participation in the Coordinated Veterans' Care Program and to Coordinated Veterans' Care Program Treatment under the program
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.7       Date of Admission for Participation in the Coordinated Veterans' Care Program
6A.8       LMO Home Care service (category C) Referral
6A.9       Procedures under the Coordinated Veterans' Care Program
 
PART 6B — TELEMONITORING TREATMENT INITIATIVE
6B.1     Telemonitoring Treatment
6B.2     Participation in the In-Home Telemonitoring for Veterans Initiative
6B.3    Approval of LMO as Participating LMO
6B.4    Payment for telemonitoring treatment
6B.5     Coordinated Veterans’ Care Program Rules to Apply
6B.6     Authorised Representative - Agent of LMO
 
PART 7 — TREATMENT GENERALLY FROM OTHER HEALTH PROVIDERS
7.1          Prior approval and financial responsibility for health services
7.1A       Notes for Providers
7.1B       Disqualified Health Care Providers
7.2          Registration or enrolment of providers
7.3          Community nursing
7.3A       MRCA Home Care Program
7.4          Optometrical services
7.5          Physiotherapy
7.6          Podiatry
7.6A       Diabetes Educator Services
7.7          Chiropractic and osteopathic services
7.7A       Outreach Program Counselling
7.8          Other services
PART 9 — TREATMENT OF ENTITLED PERSONS AT HOSPITALS AND INSTITUTIONS
9.1          Admission to a hospital or institution
9.2          Financial responsibility for Treatment In Hospital
9.3          Nursing-home-type care
9.5          Convalescent care
9.6          Other matters
PART 10 — RESIDENTIAL CARE
Part A - residential care not involving residential care (respite)
10.1        Residential care arrangements
10.4        Payment of residential care amount for certain members with dependants
Part B - residential care involving residential care (respite)
10.6     Residential care (respite) arrangements
Part C - respite admissions not involving residential care (respite)
PART 11 — THE PROVISION OF REHABILITATION APPLIANCES
11.1        Rehabilitation Appliances Program
11.2        Supply of rehabilitation appliances
11.2A     Prior Approval
11.3        Restrictions on the supply of certain items
11.4        Visual aids
11.5        Hearing aids
11.6        Other rehabilitation appliances
11.7        Repair and replacement
11.8        Treatment aids from hospitals
11.9        Provision of aids and appliances for accident prevention and personal safety
PART 12 — OTHER TREATMENT MATTERS
12.1        Ambulance transport
12.2        Treatment under Medicare
12.4        Prejudicial or unsafe acts or omissions by patients
12.6        Recovery of moneys
Transitional Provisions
 
Schedule 1      Dates for Incorporated Documents
 
 
 
 
 
Australian Government
 
MILITARY REHABILITATION AND COMPENSATION COMMISSION
 
Military Rehabilitation and Compensation Act 2004
Section 286
MRCA Treatment Principles
Instrument 2013 No. MRCC 53
 
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. 
 
1.1.2  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.  The MRCA Treatment Principles also set out:
 
(a)  the places at which, the circumstances in which, and the conditions subject to which, a particular kind or class of treatment may be provided under Part 3 of Chapter 6 of the Act;
(b)  the kinds or classes of treatment that will not be provided under Part 3 of Chapter 6 of the Act;
(c)  the places at which, the circumstances in which, and the conditions subject to which, treatment will not be provided under Part 3 of Chapter 6 of the Act;
(d)  whether the Commission’s prior approval of a particular kind or class of treatment is required under Part 3 of Chapter 6 of the Act;
(e)  if the Commission’s prior approval is required:
(i)  the circumstances in which the Commission may exercise its power to give prior approval; and
(ii)  the circumstances in which the Commission may exercise its power to give approval if the treatment was obtained without prior approval.
 
1.1.3  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.
 
1.1.4  The MRCA Treatment Principles, except the references to “SRCA disability” in paragraph 1.4.1, commences on the day after it is registered on the Federal Register of Legislative Instruments.
 
1.1.5  The references to “SRCA disability” in paragraph 1.4.1 commence on 10 December 2013.
 
Note: on 1 July 2013 the Veterans’ Affairs Legislation Amendment (Military Compensation Review and Other Measures) Act 2013 (amending Act) amended, among other Acts, the Safety, Rehabilitation and Compensation Act 1988 (SRCA) to enable certain employees (service personnel) with compensable conditions to obtain treatment for those conditions under the Veterans’ Entitlements Act 1986 or the Military Rehabilitation and Compensation Act 2004.  The amendment made by Schedule 11 of the amending Act commences on 10 December 2013.
 
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:
 
“ABN (Australian Business Number)” has the meaning given by the A New Tax System (Australian Business Number) Act 1999.
 
“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 Prime Minister and Cabinet 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
(c)  improving communication on mental injury or disease health care matters between:
(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
(c)    a Home Care service (category C); or
(d)  a limited MHC-type service;
 
to an entitled person, whether by the approved provider or a sub-contractor engaged by it.
 
“Australian Government’s Better Access initiative” means the mental health initiative described in the document entitled “Better Access to Psychiatrists, Psychologists & General Practitioners through the Medical Benefits Schedule Initiative” in force on the date in Schedule 1.
 
“Australian Centre for Posttraumatic Mental Health” and “ACPMH” mean the Australian Centre for Posttraumatic Mental Health Incorporated.
 
“authorised nurse practitioner” has the meaning it has in subsection 84(1) of the National Health Act 1953.
 
“Authorised Representative”, in relation to a medical practice in which a participating LMO is employed, means the person whose name is given as the Authorised Representative for the Practice in the form: “Application for Practice and Provider registration to In-Home Telemonitoring for Veterans Initiative” lodged with the Department of Human Services.
 
“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
 
“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 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:
 
(c) premises conducted by or on behalf of the State;
(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
              (c) Community Nurse Care Co-ordination treatment; or
              (d) Aboriginal Health Worker Care Co-ordination    treatment.
 
"co payment", in relation to the MRCA Home Care Program, 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.
 
“data repository” means a repository of telemonitoring initiative data controlled by the data repository controller for the purposes of monitoring a telemonitoring initiative participant’s physiological and behavioural data according to the telemonitoring care plan for that participant.
 
“data repository controller” means a person engaged by the Department to establish and maintain the data repository for the purposes of the In-Home Telemonitoring for Veterans Initiative.
 
“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
 
“DVA Telemonitoring Practice Incentive” means the payment of that name referred to in the “Department of Veterans’ Affairs Fee Schedules for Medical Services” and which is payable once only to the Authorised Representative for a medical practice — where, in the Commission’s opinion, all necessary steps have been taken to enable a participating LMO (and any Practice Nurse of the LMO) employed in the Practice to effectively participate in the In-Home Telemonitoring for Veterans Initiative
 
“dental hygienist” means a person registered under the National Law that provides for the registration of dental practitioners but does not include a person:
(a) whose registration to practise as a dental hygienist 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 practise as a dental hygienist.
“dental therapist” means a person registered under the National Law that provides for the registration of dental practitioners but does not include a person:
(a) whose registration to practise as a dental therapist 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 practise as a dental therapist.
 
“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
 
(c)    has been recognised as a specialist in the particular field by:
 
(i)    a Dental Board of the State or Territory in which he or she practises, where the Dental Board of the State or Territory has available a mechanism for such recognition; or
 
(ii)   another appropriate body mutually agreed in advance with the Australian Dental Association Incorporated.
 
“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.
 
“enrolment day”, in relation to a person, means the date given for a decision by a participating LMO to enrol the person as a participant in the In-Home Telemonitoring for Veterans Initiative.
 
Note: see 6B.2.4 - 6B.2.6.
 
“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.
 
“Department of Human Services” means the Department administered by the Minister administering the Human Services (Medicare) Act 1973.
 
“Department of Prime Minister and Cabinet” means the Commonwealth Department of State responsible for Commonwealth Aboriginal and Torres Strait Islander policy, programmes and service delivery.
 
“Department of Social Services” means the Commonwealth Department of State, however named, that from time to time is responsible for the administration of the Aged Care Act 1997.
 
"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
 
(c)         in remote areas, activities such as collecting firewood.
 
“elective surgery” means any non-urgent surgical procedure performed for diagnostic or therapeutic purposes.
 
"eligible young person" has the meaning it has in section 5 of the Act.
 
“emergency” means a situation where a person requires immediate treatment in circumstances where there is serious threat to the person’s life or health.
 
"emergency short term home relief" means care provided to an entitled person in his or her home on the following conditions:
 
    (a)     the person or the person's carer is unable to provide care due to sudden and unforeseen circumstances; and
 
             (b)     the period for which the care is provided does not exceed 72 hours (episode) per emergency except that, if the entitled person requires further care within 24 hours after the end of the previous episode in an emergency, and obtains prior approval, a further episode of care (up to 72 hours) may be provided in that emergency; and
                                 
    (c)     the cumulative period of the care provided to the entitled person did not exceed 216 hours in a Financial year.
 
                       Note (1):  emergency short term home relief is not relevant to the calculation of residential care amounts for residential care or residential care (respite).
                  
“entitled member" means a member or former member as defined in section 5 of the Act who is or was entitled to treatment under Part 3 of Chapter 6 of the Act and means a person with a SRCA disability.
 
“entitled person” means a person who is entitled to treatment under Part 3 of Chapter 6 of the Act.
 
Note: this includes a person with a SRCA disability.
 
“wholly dependent partner” or “wholly dependent partnerer” means a wholly dependent partner as defined in section 5 of the Act.
 
"episode of care" means services provided to a patient by a health provider that:
 
         (a)     have been detailed in a patient care plan;
 
         (b)     are characterised by continuity of treatment or provision of service;
 
         and an episode of care arises:
 
         (c)      every time a service provider sees a new patient; or
 
         (d)     where a service provider has not seen a patient for some time and therefore no continuity of service can be provided, and the original patient care plan is no longer applicable or appropriate.
 
“exceptional case process” means the process whereby the Commission may accept financial liability for community nursing services provided to an entitled person who, due to dependency or complex needs, requires community nursing services which, in the opinion of the Commission, fall significantly outside those referred to in any arrangement between the Commission and a 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
         (c) respite care;
 
         Note (1): for the purposes of this definition, "respite care" does not include centre-based day care (also called "day centre respite" or adult day activity centres").
               
Note (2): the intention is that 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.
 
“General information about VVCS – Veterans and Veterans Families Counselling Service” means the DVA document of that name in force on the date in Schedule 1 that, among other things, sets out the criteria for eligibility for VVCS.
 
“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 same meaning it has in the Classification Principles 1997 (excluding paragraph (b) of that definition).
 
Note (1): the Classification Principles 1997 are made under the Aged Care Act 1997.
Note (2): paragraph (b) of the definition of “high level of residential care” in the Classification Principles 1997 relates to “high level residential respite care” but under the MRCA Treatment Principles “residential care” and “residential care (respite)” are separate treatments
 
Note (3) the classification of residential care (non respite) as a high or low level of residential care is worked out under section 9.3B of the Classification Principles 1997.
 
"high level of residential care (respite)" means high level residential respite care described in paragraph (b) of the definition “high level of residential care” in the Classification Principles 1997.
 
Note (1): the Classification Principles 1997 are made under the Aged Care Act 1997.
 
Note (2): the classification of residential care that is respite care as a high or low level of residential respite care is worked out under section 9.3C of the Classification Principles 1997.
 
“home” includes:
 
(a)   the premises, or part of the premises, where the person normally resides; or
 
(b)   a share house where the person normally resides;
 
but does not include:
 
           (c)    a hospital; or
 
(d)         the premises where the person is receiving residential care.
 
           Note:   ‘residential care’ is also defined in paragraph 1.4.1.”.
 
"Home and Community Care Program service" means a service of Home and Community Care provided under the auspices of the Home and Community Care Act 1985.
 
"Home and Garden Maintenance" means the service, under the MRCA Home Care Program, of maintaining the home, garden or yard of an entitled person, and includes:
 
(a)         assistance with minor maintenance and minor repair of the home (e.g changing light bulbs, minor carpentry, minor painting, replacing tap washers, but not the supply of replacement items), garden or yard to keep the home, garden or yard safe and habitable;
 
(b)         lawn mowing;
 
but does not mean:
 
(c)    tree felling or tree removing or other major tasks related to a garden or yard;
 
(d)   provision of materials.
 
Note: recipients of MRCA Home Care services will be expected to supply materials used in home maintenance, eg replacement light bulbs and tap washers.  Service providers will be required to provide any equipment needed, eg garden tools.
 
“home care” has the meaning given by section 45‑3 of the Aged Care Act 1997.
 
"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
(c)      provided to an entitled person by an approved provider.
 
"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).
 
“in-home telemonitoring equipment”, for a telemonitoring initiative  participant, means apparatus (including computer software) that, in conjunction with an internet carriage service provided by an ISP Provider, enables the user of the apparatus to utilise the National Broadband Network so that the user may participate in the In-Home Telemonitoring for Veterans Initiative, and includes a video-conferencing facility.
 
“In-Home Telemonitoring for Veterans Initiative” means the Initiative of that name established by the Department which has the following features:
 
(a) telemonitoring initiative participants electronically transmit telemonitoring initiative data to the data repository using in-home telemonitoring equipment that utilises the National Broadband Network; and
 
(b) participating LMOs (or LMOs Practice Nurses) electronically retrieve telemonitoring initiative data from the data repository and analyse it for the purpose of monitoring the health of telemonitoring initiative participants.
 
“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.
 
“internet carriage service” has the meaning it has in Schedule 5 to the Broadcasting Services Act 1992.
 
“ISP Provider” means “Internet Service Provider” as defined in Schedule 5 to the Broadcasting Services Act 1992.
 
"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 and a person with a SRCA disability.
 
"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
 
(c)    does not require general anaesthesia; and
 
(d)   is not undertaken in a private day facility centre.
 
“MPPPs” means the MRCA Private Patient Principles determined by the Commission under paragraph 286(1(b) of the Act.
 
"MRCA Access Payment" means 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.
 
“National Law” means a law of the Commonwealth, a State, or Territory, enacted pursuant to the Intergovernmental Agreement for a National Registration and Accreditation Scheme for the Health Professions made on 26 March 2008:
 
http://www.ahwo.gov.au/documents/National%20Registration%20and%20Accreditation/NATREG%20-%20Intergovernmental%20Agreement.pdf
 
“National Broadband Network” has the meaning it has in the National Broadband Network Companies Act 2011.
 
“NBN” means National Broadband Network.
 
“NBN wave site” means an area, including part of an area, covered by the NBN.
 
“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.
 
“nominated residence” means a residence nominated by an entitled person as the place where the person would participate in the In-Home Telemonitoring for Veterans Initiative.
 
“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;
          (c)      a community nurse (via a DVA-contracted community nursing provider); and
          (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.
 
“Notes for Providers” means a DVA document approved by the Secretary to the Department, or by the Repatriation Commission or the Commission, or a member of either Commission, with the word ‘Notes’ in its title, and in force on the date in Schedule 1, that sets out the terms on which, and the conditions subject to which, a health care provider is to provide treatment to an entitled person in order for the Commission to accept financial responsibility for that treatment.
 
“optical dispenser”, in the case of an individual, means a person who:
 
(a) interprets optical prescriptions and fits and services optical appliances such as spectacle frames and lenses; and
 
(b) holds a qualification that, in the opinion of the Commission, is appropriate for the skills needed to practise optical dispensing; and
 
(c) is a member of a body established to supervise the occupation of optical dispenser; and
 
(d) holds a provider number as an optometrist, ophthalmologist, orthoptist or optical dispenser.
 
“optical dispenser”, in the case of a company, means a company that:
 
(a) holds an ABN (Australian Business Number);
 
(b) carries on a business of optical dispensing;
 
(c) employs or engages for the optical dispensing aspects of the business — an individual who is an optical dispenser.
 
“optical dispensing” means interpreting optical prescriptions and fitting and servicing optical appliances such as spectacle frames and lenses.
 
“oral health therapist” means a person registered under the National Law that provides for the registration of dental practitioners but does not include a person:
(a) whose registration to practice as an oral health therapist 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 practice as an oral health therapist.
Note: oral health therapists are practitioners who are dually qualified as dental therapists and dental hygienists.
 
“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.
 
“outreach program counselling” means the treatment of that name established by paragraph 7.7A.1 of the Principles — comprised of mental health counselling under the Veterans and Veterans Families Counselling Service provided by an outreach program counsellor to an entitled person eligible for the treatment under the Principles.
 
“outreach program counsellor” means:
 
(a)   a psychologist who:
 
       (i) is registered as a psychologist with the Psychology Board of Australia; and
       (ii) has been given a provider number and is eligible to provide psychological services under the Australian Government’s Better Access initiative; and
(iii) in the opinion of the Commission, has an adequate appreciation of veteran and military culture; or
 
(b)   a social worker (mental health) who:
 
(i) is accredited as a Mental Health Social Worker with the Australian Association of Social Workers; and
(ii) has been given a provider number and is eligible to provide social work services under the Australian Government’s Better Access initiative; and
(iii) in the opinion of the Commission, has an adequate appreciation of veteran and military culture;
 
being a person who does not have a written contract (described as a Deed of Standing Offer) with the Commission or the Department  in respect of the provision of a counselling service to an entitled person under the auspices of the Veterans and Veterans Families Counselling Service.
 
“participating LMO” means an LMO:
 
(a) whose name is given as a participating GP in the form: “Application for Practice and Provider registration to In-Home Telemonitoring for Veterans Initiative” lodged with the Department of Human Services; and
 
(b) who is approved in writing by the Commission to be a participating LMO in the In-Home Telemonitoring for Veterans Initiative.
 
Note: in practice a Commission delegate may grant the approval.
 
"patient care plan" means a document that is completed by a health provider who provides a service to a patient and that contains details of:
 
          (a)     the patient's medical history;
 
(b)     the injury or disease in respect of which the service is to be provided;
 
          (c)      the proposed management of the injury or disease; and
 
(d)     an estimation of the duration and frequency of the service to be provided.
 
“period of care” in relation to the care provided by:
 
          (a) an LMO; or
          (b) a practice nurse; or
(c) an aboriginal health worker; 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;
         
Note: for the purpose of ascertaining if an amount of money is a proscribed amount where the amount demanded, received or assigned is in respect of a service (s) provided during two or more weeks, without the service (s) being related to the particular week in which the service(s) was delivered, the amount shall be apportioned pro rata to those weeks.
 
(c)         subject to paragraph (b), an amount of money that if paid by an entitled person would mean the entitled person has paid, in respect of a Home Care service (category A) comprised of Personal Care provided to that entitled person by any approved provider or by any sub-contractor during a week or part thereof, an amount exceeding $10;
 
                   Note: for the purpose of ascertaining if an amount of money is a proscribed amount where the amount demanded, received or assigned is in respect of a service (s) provided during two or more weeks, without the service (s) being related to the particular week in which the service(s) was delivered, the amount                 shall be apportioned pro rata to those weeks.
 
(d)        an amount of money in respect of Respite Care provided, or to be provided, by an approved provider or by a subcontractor, to an entitled person;
     
      Note: the intention is that any amount charged for Respite Care is a proscribed amount regardless of whether it would or would not exceed $5 per hour of service.
 
(e)         an amount of money in respect of a Home Care service (category A) provided or to be provided to an entitled person that was a similar service to a Home and Community Care Program service the entitled person received immediately before 1 January 2001 and in respect of which the entitled person had not been required to pay a charge;
                  
                   Note: the intention is that any amount charged for a service similar to a free former Home and Community Care Program service previously received is a proscribed amount regardless of whether it would or would not exceed $5 per hour of service.
 
(f)          an amount of money, in respect of a Home Care service (category A) provided or to be provided to an entitled person that was a similar service to a Home and Community Care Program service the entitled person received immediately before 1 January 2001, that exceeds any amount of money the entitled person had been required to pay in respect of the Home and Community Care Program service;
     
      Note: It is the intention that any amount charged for a service similar to a Home and Community Care Program service previously received that is over and above the amount the entitled person previously paid in respect of the Home and Community Care Program service is a proscribed amount notwithstanding that the sum of the amounts that could and could not be charged did not exceed $5 per hour of service.  The limitation on the maximum amount a person could be required to pay in (a), (aa) and (b) above applies to this situation (maximum amount payable over a period).
 
(g)         an exempt amount;
     
      Note: the intention is that an exempt amount remains a proscribed amount and therefore not chargeable notwithstanding it would or would not exceed $5 per hour of service.
 
“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:
 
(c)      care provided to a person in the person’s private home; or
 
(d)     care provided in a hospital or psychiatric facility; or
 
(e)      care provided in a residential facility that primarily provides care to people who are not frail and aged.
 
"residential care amount" means:
 
(a)     in relation to a resident of a hospital — an amount determined under the Health Insurance Act 1973 to be the resident contribution applicable under that Act to a nursing-home-type patient of that hospital; or
 
(b)     in relation to a person in receipt of a high level of residential care — an amount equivalent to the maximum daily amount of resident fees worked out under Division 58 of the Aged Care Act 1997;or
Note:       ‘maximum daily amount of resident fees’ is defined in section 58-2 of the Aged Care Act 1997.
Note:       ‘standard resident contribution’ is defined in sections 58-3 and 58-4 of the Aged Care Act 1997 and does not include the ‘daily income tested reduction’ (defined in sections 44-21 to 44-23 of the Aged Care Act 1997. The effect of this is that for the purposes of determining the Commonwealth’s liability under the Act the income testing provisions of the Aged Care Act 1997 do not apply.
 
(d)     in relation to an entitled person awarded the Victoria Cross who is receiving or received a high level of residential care — an amount equivalent to the sum of:
 
                            (i) the standard resident contribution worked out under Division 58 of the Aged Care Act 1997, as that amount forms part of the maximum daily amount of resident fees; and
         
(ii) any care fee payable by the entitled person, in respect of the residential care, that is calculated by reference to the person's income.
         
                              Note: if a standard resident contribution is payable daily because it forms part of the maximum daily amount of resident fees a person is to pay, then the Commission's           financial responsibility for the standard resident contribution is for that contribution as it is incurred daily.
 
"residential care (respite)" means residential care provided as respite and includes residential care (28 day respite).
 
"residential care (28 day respite)" means residential care provided as respite for up to 28 days in a Financial year pursuant to the MRCA Home Care Program.
 
"residential care subsidy" means an amount worked out under Chapter 3 of the Aged Care Act 1997 (including any amount of veterans’ supplement) 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.
 
“revoked MRCA Treatment Principles” means the MRCA Treatment Principles (Instrument 2004 No. M21).
 
"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.
 
“SRCA” means the Safety, Rehabilitation and Compensation Act 1988.
 
“SRCA disability” means an injury (within the meaning of the Safety, Rehabilitation and Compensation Act 1988):
 
(a) for which the Military Rehabilitation and Compensation Commission has accepted liability to pay compensation under that Act; and
 
(b) for which the person with the injury is eligible to be provided with treatment under Part 3 of Chapter 6 of the Act.
Note 1:     In the Safety, Rehabilitation and Compensation Act 1988 the definition of injury includes a disease (see section 5A of that Act).
Note 2:     Section 85(2A) of the Act provides eligibility for treatment of a person with an injury under the Safety, Rehabilitation and Compensation Act 1988.
 
“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.
 
“telemonitoring care plan” means a care plan prepared by a participating LMO in conjunction with a telemonitoring initiative participant that:
 
(a)   is based on the electronic transmission of telemonitoring initiative data and;
(b)   satisfies the minimum requirements for a GPMP (General Practitioner Management Plan), as if the telemonitoring care plan is to be a GPMP, as set out in the Notes for Coordinated Veterans' Care Program Providers.
 
“telemonitoring equipment”, for a participating LMO, means computer software and similar tools that will enable the participating LMO (or the LMOs Practice Nurse) to participate in the In-Home Telemonitoring for Veterans Initiative.
 
“telemonitoring initiative data” means physiological and behavioural data about a telemonitoring initiative participant (participant), assembled with reference to the telemonitoring care plan for the participant, and transmitted by the participant, or by a person on the participant’s behalf, to the data repository via the participant’s in-home telemonitoring equipment where it may be electronically retrieved by the participating LMO for the participant or the LMOs Practice Nurse.
 
“telemonitoring initiative participant” means an entitled person who has in-home telemonitoring equipment installed in the person’s nominated residence and who has been enrolled in the In-Home Telemonitoring for Veterans Initiative by a participating LMO.
 
“telemonitoring treatment” means treatment provided by a participating LMO (or the LMO’s Practice Nurse), a data repository controller, a contractor or an ISP provider, as the case may be, under Part 6A.
 
“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.
 
“Veterans and Veterans Families Counselling Service” or “VVCS” means the service funded by the Department of Veterans’ Affairs that provides free, confidential and Australia-wide mental health counselling and group programs to Australian veterans, peacekeepers, their families, eligible current serving Australian Defence Force members and F-111 workers and their families.
 
“VVCS criterion” means a criterion in the DVA document “ General information about VVCS – Veterans and Veterans Families Counselling Service” under the heading “Who can use VVCS?”, being a criterion that relates to a person who is eligible for treatment under the Act.
 
 
“VVCS OPC Provider Notes” means the document approved by the Commission, the Repatriation Commission, a member of the Commission or Repatriation Commission or by the Secretary to the Department, entitled “ Veterans and Veterans Families Counselling Services (VVCS) Outreach Program Counsellors (OPC) Provider Notes”, and in force on the date in Schedule 1, that sets out the terms on which an outreach program counsellor is to provide outreach program counselling to an eligible entitled person.
 
“service injury” and “service disease” are defined in section 5 of the Act; and in relation to a person with a SRCA disability mean the person’s injury (within the meaning of the Safety, Rehabilitation and Compensation Act 1988) that was caused by, or arose out of, the person’s employment in the Defence Force that is covered by the Safety, Rehabilitation and Compensation Act 1988.
 
Note: in the Safety, Rehabilitation and Compensation Act 1988 the definition of injury includes a disease (see section 5A of that Act).
 
“veterans’ supplement”, in relation to an entitled person, means the supplement of that name that applies under the Aged Care Act 1997 to the person as a care recipient under that Act.
 
Note (1): see s.44-5 of the Aged Care Act 1997.
 
Note (2): until 1 July 2014 the Residential Care Subsidy Principles 1997 and the Home Care Subsidy Principles 2013 under the Aged Care Act 1997 may specify, in respect of a veterans’ supplement, the circumstances in which the supplement will apply to a care recipient in respect of a payment period.  On/after 1 July 2014, the Residential Care Subsidy Principles 1997 and the Home Care Subsidy Principles 2013 will be consolidated in the Subsidy Principles under the Aged Care Act 1997.
 
"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.
 
Note: a White Card is issued to a person with a SRCA disability.
 
1.4.2  In the MRCA Treatment Principles, if a Note follows a principle, paragraph or subparagraph, the Note is taken to be part of that principle, paragraph or subparagraph, as the case may be.
 
PART 2 — ENTITLEMENT TO TREATMENT
2.1     Treatment for entitled persons in Australia
2.1.1  Subject to these Principles, the Commission may provide or arrange for treatment in Australia of:
 
(a)   entitled persons who have been issued with:
 
(i)    a Gold Card; or
 
(ii)   a White Card; or
 
(iii)  a written authorisation issued on behalf of the Commission; and
 
2.2      Treatment for entitled persons residing or travelling overseas
2.2.1  Subject to these Principles, the Commission will accept financial responsibility for the treatment overseas of service injuries or service diseases only for:
 
(a)   a member or former member who is resident overseas; or
 
(b)   a member or former member who is travelling overseas.
 
2.2.2  Except where the Commission decides otherwise, the Commission will not accept financial responsibility under paragraph 2.2.1 for costs incurred in the treatment of a service injury or disease injury or disease while a member or former member is temporarily absent from Australia unless, prior to departure, an office of the Department has been notified of the member's or former member’s intention to travel.
 
2.2.3  Except in an emergency, for treatment other than residential care or residential care (respite), financial responsibility under paragraph 2.2.1 will be limited to:
 
(a) the cost of treatment provided in accordance with the mode and duration that would have been provided or arranged, under these Principles, in Australia; or
 
(b) the cost of treatment provided by a health authority or facility nominated by the Commission.
 
Treatment that is residential care/residential care (respite)
 
2.2.4  For treatment that is residential care or residential care (respite), financial responsibility under paragraph 2.2.1 will be limited to:
 
(a) in the case of residential care provided for a period to a member or former member, whether provided in an emergency or not — the lesser of:
 
          (i) the amount charged the member or former member; or
                            (ii) an amount equal to the amount of residential care subsidy payable for a person given a high level of residential care for the same period in Australia plus any residential care amount the Commission would have accepted for the member or former member in Australia;
 
(b) in the case of residential care (respite) provided for a period to a member or former member, whether provided in an emergency or not — the lesser of:
 
          (i) the amount charged the member or former member; or
                            (ii) an amount equal to the amount of residential care subsidy payable for a person given a high level of residential care (respite) for the same period in Australia (not exceeding 63 days in a Financial year) plus any residential care amount the Commission would have accepted for the member or former member in Australia.
            
             Note (1): Subject to the Principles, the Commission will not accept financial responsibility for medical or allied-health treatment applied to an injury or disease of a member or former member that is not a service injury or a service disease.
            
               Note (2): By virtue of Part 10 of the Principles the Commission, in the first instance, rather than the Commonwealth, accepts financial responsibility for the provision of residential care and residential care (respite) under the Aged Care Act 1997 to entitled persons.
                     
                         Note (3): the "residential care amount", also commonly known as the "basic daily care fee" or "resident fee", is the amount to be worked out under section 58-3, or the amount to be worked out under subsection 58-4(1), of the Aged Care Act 1997 as amended from time to time, depending on which of those provisions applied to the circumstances of the member or former member.
 
(d)     in the case of residential care (respite), the cost of that care (as worked out under paragraph (c)) for only a maximum of 63 days in any Financial year.
 
Note (1):the intention is that the Commission will not accept any further financial responsibility for "a respite admission" in a Financial year where in that year the person had already spent 63 days in residential care as a respite admission.
               
                Note (2): for the purpose of calculating the number of days spent by a member in residential care (respite) in a Financial year, any day spent in residential care (respite) in Australia in that year is also to be taken into account.
 
2.2.5  Notwithstanding paragraphs 2.2.2 or 2.2.3, the Commission will not be responsible for treatment costs incurred by any person who travels overseas from Australia where a significant reason for that travel is to obtain treatment or rehabilitation appliances.
 
          No Overseas MRCA Home Care or HomeFront
 
2.2.8           The Commission will not accept financial liability for the provision overseas of treatment under the MRCA Home Care Program or under the HomeFront Program.
 
Note: the HomeFront Program is the common name given to accident prevention and personal safety treatment provided under paragraphs 11.9.1 to and including paragraph 11.9.8 of the Principles.
 
2.3     Treatment of associated non-service injury or disease injuries or diseases
2.3.1  Subject to these Principles, the Commission will provide, arrange, or accept financial responsibility for treatment of an injury or disease that is not a service injury or a service disease to the extent that it is a necessary part of treatment for a service injury or service disease.
 
2.6     Referrals by the Veterans and Veterans Families Counselling Service
2.6.1  The Veterans and Veterans Families Counselling Service may refer its clients who are members to other counselling services.
 
2.6.2  The Commission will accept financial responsibility for counselling referred under paragraph 2.6.1 only where that referral is in accordance with guidelines prepared by the Commission.
Note: The guidelines are prepared by the Commission after, and subject to, consideration of advice from the National Advisory Committee on the Veterans and Veterans Families Counselling Service.
 
 
 
 
2.7A   Centre for Military and Veterans’ Health Treatment
 
2.7A.1    The Commission may accept financial liability for CMVH treatment provided for the benefit of an entitled member who is entitled to such treatment under the Act.
 
Note (1): under subsection 13(1) of the Act treatment can be action taken with a view to maintaining a person in physical or mental health.
 
Note (2): the intention is that the Commission may accept liability for CMVH treatment even though such treatment is not provided by the Centre for Military and Veterans’ Health.
 
Note (3): prior approval for CMVH treatment is not required.
 
2.7B   Australian Centre for Posttraumatic Mental Health Treatment
 
2.7B.1    The Commission may accept financial liability for ACPMH treatment provided for the benefit of an entitled member who is entitled to such treatment under the Act.
 
Note (1): under subsection 13(1) of the Act treatment can be action taken with a view to maintaining a person in physical or mental health.
 
Note (2): the intention is that the Commission may accept liability for ACPMH treatment even though such treatment is not necessarily provided by the Australian Centre for Posttraumatic Mental Health but under its auspices.
 
Note (3): prior approval for ACPMH treatment is not required.
 
2.8     Loss of eligibility for treatment
2.8.1    The Commission will not accept financial responsibility for treatment provided to a person if that person is not, in the Commission's opinion, entitled to the treatment.
 
2.8.2    Where a person was entitled to treatment but is considered by the Commission to no longer be entitled to treatment or the person has received treatment for which, in the Commission's opinion, he or she was not entitled, the Commission or an employee of the Department must make a reasonable effort to notify the person that they are not entitled to treatment .
 
 
PART 3 — COMMISSION APPROVAL FOR TREATMENT
3.1     Approval for treatment
3.1.1 The Commission’s prior approval may be required for treatment.
 
3.2     Circumstances in which prior approval is required
3.2.1  Treatment requiring prior approval includes:
 
(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 9.1.9.
 
(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 or in a DVA document incorporated into the Principles;
 
(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 a visual aid to an entitled person by an optometrist or an optical dispenser that is either:
 
(i) not available to the entitled person under the DVA document entitled “Pricing Schedule for Visual Aids”, in force on the date in Schedule 1; or
 
(ii) available to the entitled person under the DVA document entitled “Pricing Schedule for Visual Aids”, in force on the date in Schedule 1, but with the stipulation that prior approval is required.
 
(t)    repair of a rehabilitation appliance specified as requiring prior approval in or under Part 11;
 
(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;
 
(za) treatment specified in any Notes for Providers (however described) and in any Fee Schedule as requiring prior approval.
 
3.2.2  In considering whether prior approval will or will not be given and what conditions, if any, will apply, the following will be taken into account:
 
(a)   any specific requirements contained in these Principles or the Act;
 
(c)    the extent of funds that are available;
 
(d)   reasonable control over expenditure;
 
(e)    the clinical need for the proposed treatment; and
 
(f)    the suitability and quality of the proposed treatment.
 
3.3     Circumstances in which prior approval is not required
3.3.2  Treatment not requiring prior approval includes:
 
(a)   treatment by Local Medical Officer or other GPs except where otherwise indicated in Part 4;
 
(b)   medical specialist consultations in country and Territory areas, except where otherwise indicated in principle 4.7;
Note:      Prior approval is not required for medical specialist consultations in States or Territories where the MPPPs apply — see paragraph 1.2.2.
 
(c)   dental treatment specified as not requiring prior approval in Part 5 or in a DVA document incorporated into the Principles;
 
(d)   dental prosthetic treatment specified as not requiring prior approval in Part 5 or in a DVA document incorporated into the Principles;
 
(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 dispenser) provided that, if an optical product is dispensed, any requirement for prior approval in relation to that product imposed by 3.2.1(s) is satisfied.
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.
 
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 ¾ 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), including for dental services provided by a dental hygienist, dental therapist or oral health therapist on behalf of the dentist ¾ 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 ¾ 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, including for dental services provided by a dental hygienist, dental therapist or oral health therapist on behalf of the dental specialist ¾ 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 ¾ 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 ¾ 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 ¾ 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 ¾ 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 ¾ 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 ¾ 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) ¾ 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 ¾ 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, the DVA document entitled “Pricing Schedule for Visual Aids”, in force on the date in Schedule 1, 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 ¾ 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 ¾ 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 ¾ 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 ¾ the amount worked out under the Notes for Local Medical Officers in respect of an other GP;
 
(oa)   an outreach program counsellor — the amount worked out under the DVA document entitled “Veterans and Veterans Families Counselling Service (VVCS) Outreach Program Counsellors (OPC) 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 VVCS OPC Provider Notes as the Notes apply to the person as a psychologist or social worker (mental health), as the case may be;
 
(p)     a physiotherapist ¾ 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 ¾ 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 ¾ 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 ¾ 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) ¾ 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) ¾ 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 ¾ 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
 
(c)          if a claim for payment in respect of treatment:
 
(i)                is in the form, if any, approved by the Commission for this purpose ('approved form'); and
(ii)             contains, or is accompanied by, any information required by any direction in any approved form; and
 
(iii)           is lodged at an appropriate place or with an appropriate person within the period of 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 care 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
 
(c)    examination for employment purposes; or
 
(d)   examination for a medical certificate for membership of a friendly society.
 
3.5.4   Where the Commission accepts financial responsibility under these MRCA Treatment Principles, it does so on behalf of the Commonwealth.
 
PART 4 — MEDICAL PRACTITIONER SERVICES
4.1    Medical Practitioner Services
 
4.1.2 Outline
 
4.1.3 The aim of the medical services program is to ensure that as far as practicable entitled persons have access to free, safe and cost-effective treatment.
 
To achieve this objective the Commission or the Department deals with medical practitioners on three levels.
 
At the first level the Commission or the Department deals with medical practitioners called LMOs.  Services provided by these medical practitioners must be in accordance with these Principles and the Notes for Local Medical Officers if the Department is to pay for the services.
 
The second level of engagement is where the Commission or the Department deals with medical practitioners who are willing to treat entitled persons under these Principles eg without charging the entitled person, but who are not prepared to provide their services in accordance with the Notes for Local Medical Officers.  These medical practitioners are called other GPs.
 
Because LMOs provide services in accordance with the Notes for Local Medical Officers, which impose various requirements, some of which are exacting but which are aimed at maintaining a high quality of service and ensuring accountability, they receive higher rates of remuneration from the Department than do other GPs.
 
The feature that distinguishes LMO-treatment or other GP-treatment from treatment provided by medical practitioners not included in these categories is that LMOs and other GPs do not charge the entitled person for that treatment.  They charge the Commission, the Department or Department of Human Services (hereafter in this Outline these bodies are referred to collectively as DVA).
 
It should be noted that while it is the Commission that accepts financial liability for treatment it is the Department (Commonwealth) that actually pays for the treatment.
 
The third level of interaction between the Commission or the Department and medical practitioners is where the medical practitioner is a specialist. 
 
Unlike LMOs, medical specialists (as at 1 April 2006) are not prepared to submit to the same level of regulation as LMOs regarding services to entitled persons (at DVA expense) but if they are prepared to treat an entitled person at the rate set out in the Principles and charge DVA and not the entitled person, then the relationship between DVA and the specialist is covered by the Principles.
 
4.1.4  Subject to paragraph 3.5.1, the Commission may accept financial liability for medical treatment provided to an entitled person by an LMO, an other GP or a medical specialist.
 
Note: paragraph 3.5.1 sets out the financial limits on Commission liability for treatment.
4.2     Providers of services
4.2.1 Unless otherwise indicated in these Principles, an entitled person may be provided with only those services included in the Medicare Benefits Schedule.
 
4.2.2  The services referred to in paragraph 4.2.1 may be provided only by:
 
(a)   a Local Medical Officer or other GP; or
 
(b)   a medical specialist.
 
4.2.3 (1) An entitled person may be provided with services that are not made available under the Medicare Benefits Schedule ("unlisted services"). 
 
(2) Unlisted services are not to be provided to an entitled person if the Commission is satisfied that they are:
 
(a) a mere improvement on existing Medicare Benefits Schedule listed services; or
 
(b) experimental and have not been demonstrated to be effective or safe by extensive clinical trials.
 
4.2.4 Subject to paragraph 4.2.3(2), unlisted services are to be provided to an entitled person under paragraph 4.2.3(1) if the Commission is satisfied that the services will provide a substantial benefit to the health of the entitled person.
 
Note 1: the prior approval of the Commission is required before unlisted services may be provided (Paragraph 3.2.1 (b)).
 
Note 2: the availability of funds and the need to reasonably control expenditure are factors to be considered in granting prior approval (Subparagraphs 3.2.2 (c) and (d))
   
4.2.5  The services referred to in paragraph 4.2.3 may be provided only by:
 
(a)   a Local Medical Officer or other GP; or
 
(b)   a medical specialist.
 
4.2.6  Optical Coherence Tomography
 
4.2.7  The Commission may accept financial responsibility for Optical Coherence Tomography (OCT) provided to an entitled person by an Ophthalmologist for the assessment or management of retinal disease.
 
Note: While OCT remains an unlisted treatment it is subject to all the requirements for an unlisted treatment except prior approval.
 
4.3     Financial responsibility
4.3.1  Subject to paragraph 3.5.1, and unless otherwise indicated in these Principles, the Commission will accept financial responsibility for treatment costs where a Local Medical Officer or other GP or specialist provides or arranges for treatment of:
 
(a)         an entitled person who has been issued with a Gold Card; or
 
(b)   an entitled person who has been issued with a White Card for any service injury or service disease; or
 
(c)    a person who has been issued with a written authorisation on behalf of the Commission;
 
Note: Principle 3.5.1 also deals with financial liability for medical practitioner fees.
 
4.3.2  In relation to any occasion of service to an entitled person under these Principles, a Local Medical Officer or other GP or specialist shall bill only:
 
(a) the Department; or
 
           (b) the Commission; or
 
           (c) the Department of Human Services,
 
and that bill shall be for full settlement of the account for the service provided to the entitled person.
 
4.3.3  Any billing method described in paragraph 4.3.2 may be used on each occasion of service.
 
4.3.4  Subject to paragraph 4.7.3, the Commission will accept financial responsibility for any of the services described in paragraph 4.4.1, irrespective of the billing arrangement chosen under paragraph 4.3.2 by the referring Local Medical Officer or other GP or specialist.
 
4.3A           Disqualified Medical Practitioners
 
4.3A.1        The Commission is not to accept financial responsibility for the cost of a medical service provided to an entitled person by, or on behalf of, a LMO, other GP or a medical specialist if, at the time the service was provided, a medicare benefit would not have been payable in respect of the service under section 19B or section 19C of the Health Insurance Act 1973 (in force from time to time) if the LMO, other GP or medical specialist had provided the service as a practitioner under that Act.
 
4.4     Referrals
4.4.1  A Local Medical Officer or other GP may refer an entitled person for:
 
(a)   treatment from a medical specialist, subject to paragraph 4.7.1, and principles 4.5 to 4.8;or
 
(b)   treatment from a Local Medical Officer or other GP who has expertise or recognition in a particular field but is not a qualified medical specialist, subject to principles 4.5 to 4.8;or
 
(c)    treatment in a hospital or other institution as indicated in these Principles; or
 
(d)   other health-care services not requiring prior approval, as indicated in principles 7.3, 7.5 and 7.6.
 
4.5     Referrals by medical specialists
4.5.1  In providing treatment, a medical specialist, to whom an entitled person is referred under these Principles, may:
 
(a)   arrange diagnostic tests;or
 
(b)   refer the entitled person to another specialist in the same way as may a Local Medical Officer or other GP;or
 
(c)    arrange treatment in a hospital or other institution as indicated in these Principles; or
 
(d)   refer the entitled person to a health-care provider in accordance with principles 7.3, 7.5 or 7.6, in the same way as may a Local Medical Officer or other GP.
 
4.7     Referrals: prior approval
4.7.1  In all instances other than those described in paragraph 4.7.3 and the MRCA Private Patient Principles 2004, prior approval is required for the referral of entitled persons to medical specialists.
 
4.7.2  Prior approval is required for:
 
 
(a)   the provision of psychotherapy treatment to entitled persons; or
 
(b)   the provision of services under paragraph 4.2.3.
 
4.7.3  Prior approval is not required when a LMO, other GP or medical specialist refers an entitled person to a medical specialist for diagnostic imaging or pathology services not requiring admission and the medical specialist direct bills the Department of Human Services at 100 per cent or less of the fee set out in the Medicare Benefits Schedule as full settlement of the account for the service rendered.
 
4.8     Other matters
4.8.1  The Commission will not accept financial responsibility for the cost of:
 
(a)   elective surgery undertaken without prior approval with the exception of elective surgery in a public hospital, minor procedures carried out in a Local Medical Officer or other GP’s or specialist’s rooms where the only charge is equivalent to the charge that would be applicable under the Medicare Benefits Schedule for that procedure; or
 
(b)   examination for a medical certificate for life assurance purposes; or
 
(c)    examination for a medical certificate for membership of a friendly society; or
 
(d)   examination for employment purposes; or
 
(e)    multi-phasic screening; or
 
(f)    services where the cost is otherwise recoverable wholly or partly, by way of a legal claim; or
 
(g)   services that have been paid for, wholly or partly, by the Department of Human Services, as a medicare benefit, or by a health insurance fund; or
 
(ga)  diabetes educator services under this Part that may be provided under Part 7 (Treatment Generally From Other Health Providers).
 
 
 
PART 5 — DENTAL TREATMENT
5.1     Providers of services
5.1.1  The Commission may accept financial responsibility for dental treatment provided to an entitled person by a dental prosthetist, dentist or dental specialist where the treatment is provided in accordance with these Principles and in accordance with the Notes for Allied Health Providers (Section 1 General Information and Section 2(c)(as section 2(c) affects a dental prosthetist, dentist or dental specialist, as the case may be)).
 
5.1.1A For paragraph 5.1.1, dental treatment provided by a dentist or dental specialist includes dental treatment provided by a dental hygienist, dental therapist or oral health therapist on behalf of the dentist or dental specialist, as the case may be.
 
5.1.2  The Commission will accept financial responsibility for dental treatment provided to an entitled person in a Tier 1 Hospital or Contracted Day Procedure Centre without the need for prior approval.
 
Note: the Notes for Allied Health Providers, the “Fee Schedule of Dental Services for Dentists and Dental Specialists” and the “Fee Schedule of Dental Services for Dental Prosthetists”, as incorporated-by-reference into the Principles, could be relevant to dental treatment provided to an entitled person in a hospital.
 
5.1.2A Except in an emergency, the Commission’s prior approval is required before dental treatment is provided to an entitled person in a hospital other than a Tier 1 Hospital or on premises other than a Contracted Day Procedure Centre unless the “Fee Schedule of Dental Services for Dentists and Dental Specialists” or the “Fee Schedule of Dental Services for Dental Prosthetists” provides that prior approval is not required for the treatment.
 
5.1.3  Subject to prior approval, an entitled person may be referred to a dental specialist by a dental prosthetist, dentist or other dental specialist.
 
5.2      Financial responsibility
5.2.1  The DVA document entitled “Fee Schedule of Dental Services for Dentists and Dental Specialists”, in force on the date in Schedule 1, and comprised of Dental Schedules A, B and C, lists the dental services provided by dentists, or dental specialists, for which the Commission will accept financial responsibility, when provided to an entitled person, and sets out the limits of that financial responsibility.
 
5.2.2  The DVA document entitled “Fee Schedule of Dental Services for Dental Prosthetists”, in force on the date in Schedule 1, lists the dental services provided by dental prosthetists for which the Commission will accept financial responsibility, when provided to an entitled person, and sets out the limits of that financial responsibility.
 
5.2.3  Dental Schedule C in 5.2.1 imposes a monetary limit (annual monetary limit) in respect of dental services provided to an entitled person under that Schedule in a Calendar year.
 
5.2.4  Subject to 5.1.2 and 5.1.2A (treatment in Tier 1 Hospital/Contracted Day Procedure Centre), where a Schedule in 5.2.1 or 5.2.2 specifies a need for prior approval in respect of a service, the Commission is not to accept financial liability for the service unless it has granted prior approval or retrospective approval for the service.
 
5.2.5  The annual monetary limit set under Dental Schedule C in 5.2.1 will not apply in relation to a dental service where that service is for a service injury or service disease.
 
5.2.6  Subject to paragraph 5.5.1, the Commission will not accept financial responsibility for dental treatment after a person is no longer entitled to the treatment.
 
5.2A           Disqualified Dental Practitioners
 
5.2A.1        The Commission is not to accept financial responsibility for the cost of a dental service provided to an entitled person by, or on behalf of, a dental prosthetist, dentist or a dental specialist 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 dental prosthetist, dentist or dental specialist had provided the service as a practitioner under that Act.
 
5.3     Entitlement
5.3.1  Subject to these Principles, an entitled person who holds a Gold Card, White Card or written authorisation issued on behalf of the Commission, may be provided with dental services at the expense of the Commission.
 
5.3.2  A person who holds a Gold Card will be provided with the following dental services:
 
(a)     for treatment of an injury or disease that is not a service injury or a service disease:
 
(i)      the dental services listed in Schedules A, B and C of the DVA document entitled “Fee Schedule of Dental Services for Dentists and Dental Specialists”, in force on the date in Schedule 1 — on condition the services are provided in accordance with those Schedules;
 
                   Note: Schedule C imposes an annual monetary limit.
 
(ii)     the dental services listed in the DVA document entitled “Fee Schedule of Dental Services for Dental Prosthetists”, in force on the date in Schedule 1 — on condition the services are provided in accordance with that Schedule.
 
(b)     for treatment of a service injury or service disease:
 
(i)      the dental services listed in Schedules A, B and C of the DVA document entitled “Fee Schedule of Dental Services for Dentists and Dental Specialists”, in force on the date in Schedule 1 — on condition the services are provided in accordance with those Schedules (but without the annual monetary limit in the Schedule C);
 
(ii)     the dental services listed in the DVA document entitled “Fee Schedule of Dental Services for Dental Prosthetists”, in force on the date in Schedule 1 — on condition the services are provided in accordance with that Schedule.
 
5.3.3  A person who holds a White Card is entitled to dental treatment of a service injury or service disease and will be provided with:
 
(a)     the dental services listed in the DVA document entitled “Fee Schedule of Dental Services for Dentists and Dental Specialists”, in force on the date in Schedule 1 — on condition the services are provided in accordance with that Schedule; and
 
Note: Schedule C of the Fee Schedule imposes an annual monetary limit
 
(b)     the dental services listed in the DVA document entitled “Fee Schedule of Dental Services for Dental Prosthetists”, in force on the date in Schedule 1 — on condition the services are provided in accordance with that Schedule.
 
5.4     Emergency dental treatment
5.4.1  Prior Approval is not necessary for emergency dental treatment provided to an entitled person where the treatment is provided in accordance with:
 
(a)     the Principles;
(b)     the “Fee Schedule of Dental Services for Dentists and Dental Specialists”, in force on the date in Schedule 1;
(c)      the “Fee Schedule of Dental Services for Dental Prosthetists”, in force on the date in Schedule 1; and
(d)     the Notes for Allied Health Providers;
 
as those documents relate to the treatment, but if prior approval is required for the treatment then the Commission’s retrospective approval for the treatment must be sought as soon as possible after the treatment is provided and approval must be granted if the Commission is to accept financial liability for the emergency dental treatment.
 
Note: Schedule C of the “Fee Schedule of Dental Services for Dentists and Dental Specialists” imposes an annual monetary limit
 
5.4.2  Financial responsibility for emergency dental treatment for persons who hold a White Card will only be accepted for treatment of a service injury or service disease.
 
5.5     Orthodontic treatment for children
5.5.1  Orthodontic treatment will continue to be provided for an eligible young person of a deceased member if the eligible young person has ceased to be eligible for treatment because he or she has turned sixteen years of age or has ceased full-time education if:
 
(a)   the treatment is approved by the Commission while the eligible young person is still eligible; and
 
(b)   the treatment is commenced while the eligible young person is still eligible; and
 
(c)    the treatment will be completed within two years of commencement of treatment or such longer time as the Commission considers reasonable.
 
5.6     General anaesthesia
5.6.1  Financial responsibility for a general anaesthetic provided as part of dental treatment will be accepted only if:
 
(a)     the anaesthetic is administered by a specialist anaesthetist or approved medical practitioner in a hospital, Day Procedure Centre or dental surgery where adequate resuscitation equipment is provided; and
 
(b)     unless the anaesthetic is administered in a Tier 1 Hospital or Contracted Day Procedure Centre — prior approval has been obtained.
 
5.7     Prescribing of pharmaceutical benefits by dentists
5.7.1  Local Dental Officers or dental specialists may prescribe Pharmaceutical Benefits for entitled persons.
 
5.7.2  Subject to paragraph 5.7.4, prescriptions prescribed under paragraph 5.7.1 must be in accordance with the PBS.
 
5.7.3  The Commission will accept financial responsibility for Pharmaceutical Benefits, available under the PBS that are required as part of dental treatment:
 
(a)    for a service injury or service disease of an entitled person who holds a White Card; or
 
(b)   for an entitled person who holds a Gold Card;
 
other than the amount that would have been payable by the person if the person were a “concessional beneficiary” under the National Health Act 1953.
 
5.7.4  The Commission will accept financial responsibility for Pharmaceutical Benefits that are not available under the PBS and are required as part of dental treatment:
 
(a)    for a service injury or service disease of a person who hold a White Card; or
 
(b)   for a person who holds a Gold Card;
 
but such a prescription must be written on a private prescription.
 
5.8     Other dental services
5.8.1  The Commission will not accept financial responsibility for dental treatment that involves the use of intravenous sedation or relative analgesia technique in a Local Dental Officer’s or dental specialist’s surgery.
 
 
PART 6 — PHARMACEUTICAL BENEFITS

6.1     MRCA Pharmaceutical Benefits Scheme
6.1.1  The MRCA Pharmaceutical Benefits Scheme (prepared by the Commission under paragraph 286(1)(c) of the Act) relates to the supply of Pharmaceutical Benefits to entitled persons by community pharmacists as defined in that Scheme.
 
6.2     Entitlement under the MRCA Pharmaceutical Benefits Scheme
6.2.1  A person is eligible to receive Pharmaceutical Benefits under the MRCA Pharmaceutical Benefits Scheme if that person holds:
 
(a)    a White Card for a service injury or service disease; or
(b)   a Gold Card.
 
 
PART 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;
(c)   store the approval in a readily retrievable form; and
(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;
 
(c)      notify the entitled person, in a manner the LMO considers appropriate, 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;
                                      (c) Community 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.4A         Arrangements with Service Providers
 
6A.4A.1      For the purpose of facilitating the provision of Coordinated Veterans' Care Program treatment to entitled persons, the Commission or the Department may enter into an arrangement with a person to:
 
(a) assist in identification of possible participants in the Coordinated Veterans' Care Program and provide general support to the Commission or Department in respect of the program including:
 
(i) data analysis to identify and notify potential participants and their usual LMO or medical practitioner;
(ii) undertaking ongoing analysis and reporting to support program evaluation and monitoring;
(iii) promoting the program and providing supplementary support materials for LMOs and participants in the Program; or
 
(b) deliver training modules and resources in Chronic Disease Management to LMOs, medical practitioners, Practice Nurses and Community Nurses; or
 
(c) undertake ongoing and independent monitoring and evaluation of the Coordinated Veterans' Care Program.
 
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
 
                                      (c)      the entitled person has complex care needs for the condition in (1)(a), being:
 
(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
                                                (c) the person is participating in a health care program provided by the Department of Health or the Department of Social Services known as:
                                          
                                                (i) “Coordinated Care for Patients with Diabetes” (including as a pilot program); or
(ii) “Transition Care”;
                                     
                                                or in a similar coordinated health care program provided by that Department that is essentially the same as one in (i) or (ii) 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 6B – TELEMONITORING TREATMENT INITIATIVE
 
6B.1  Telemonitoring Treatment
 
6B.1.1 A treatment (telemonitoring treatment) is established by this Part and may be arranged by the Commission for an entitled person, in the circumstances, and subject to the conditions, set out in this Part.
 
6B.1.2 Telemonitoring treatment is comprised of:
 
(a) in respect of a participating LMO (or the LMO’s Practice Nurse):
 
(i)    monitoring the health of a telemonitoring initiative participant (participant) in accordance with the telemonitoring care plan, including monitoring the  telemonitoring initiative data for the participant;
 
(ii)   taking any appropriate healthcare action in response to telemonitoring initiative data;
 
Note: an example of appropriate action could be the LMO arranging a face-to-face consultation or video consultation with the telemonitoring initiative participant.
 
(iii)  disclosing the telemonitoring initiative data to the Department or to any consultant acting for the Department in the In-Home Telemonitoring for Veterans Initiative; and
 
(iv)  taking action reasonably incidental to any of the above actions.
 
Note: in practice an LMO could delegate some of the LMO’s functions in the In-Home Telemonitoring for Veterans Initiative to the LMO’s Practice Nurse e.g. electronically retrieving telemonitoring initiative data from the data repository, evaluating it and instituting care planning based on that evaluation.  In this situation the Practice Nurse, as the employee or agent of the LMO, is acting on the LMO’s behalf and the Practice Nurse’s actions constitute telemonitoring treatment as if those actions had been performed by the participating LMO.
 
(b) in respect of the data repository controller:
 
(i)    training a participating LMO (including staff of the participating LMO such as a Practice Nurse) in:
 
(a)     the use of telemonitoring equipment; and
(b)     the electronic retrieval of telemonitoring initiative data from the data repository; and
(c)      electronically accessing and using any video consultation between the participating LMO and the telemonitoring initiative participant; and
(d)     the use of any other tools necessary for monitoring the telemonitoring initiative participant’s condition for the In-Home Telemonitoring for Veterans Initiative;
 
(ii)   training a telemonitoring initiative participant (participant) or a person on behalf of the participant, in the use of in-home telemonitoring equipment necessary for the participant’s participation in the In-Home Telemonitoring for Veterans’ Initiative and, if need be, supplying that equipment (including leasing it);
 
(iii)  maintaining in-home telemonitoring equipment (equipment) and providing technical assistance in respect of that equipment when necessary;
 
(iv) maintaining the data repository;
 
(v)   taking action reasonably incidental to any of the above actions.
 
(c) in respect of a person (contractor) engaged by the Department to train Practice Nurses for the purposes of the In-Home Telemonitoring for Veterans’ Initiative:
 
(i) training a participating LMO’s Practice Nurse in telemonitoring initiative data evaluation and care planning and care planning co-ordination based on that evaluation;
 
(d) in respect of an ISP provider, its action of enabling a telemonitoring initiative participant to use in-home telemonitoring equipment.
 
Note: the ISP provider would connect the telemonitoring initiative participant’s equipment to the NBN.
 
6B.2  Participation in the In-Home Telemonitoring for Veterans Initiative
 
6B.2.1         An entitled person is eligible for participation in the In-Home Telemonitoring for Veterans Initiative as a telemonitoring initiative participant if the person:
 
(a) holds a Gold Card; and
 
(b) is admitted to, or in the opinion of the participating LMO for the person is likely to be admitted to, the Coordinated Veterans' Care Program; and
 
(c) has one or more of the following chronic conditions:
 
(i) congestive heart failure;
(ii) coronary artery disease;
(iii) chronic obstructive pulmonary disease;
(iv) diabetes; and
 
(d) does not have a severe unstable co morbidity; and
 
(e) is not receiving residential care; and
 
(f) has been assessed by a participating LMO for the person to be suitable for the In-Home Telemonitoring for Veterans Initiative in terms of, among other relevant factors, the person’s cognitive ability to be trained in the use of in-home telemonitoring equipment, where the equipment will not be operated by a person on behalf of the entitled person; and
 
Note: where a person (carer) will operate in-home telemonitoring equipment on behalf of the potential telemonitoring initiative participant (participant), the carer must be assessed by the participating LMO as having the cognitive ability to be trained in the use of the equipment in order for the participant to be eligible for participation in the In-Home Telemonitoring for Veterans Initiative.
 
(g) is the subject of a telemonitoring care plan prepared by the participating LMO for the person which was prepared in conjunction with the person; and
 
(h) resides in an NBN wave site; and
 
(i) nominates a residence (nominated residence) for the purposes of the person participating in the In-Home Telemonitoring for Veterans Initiative; and
 
(j) consents to the disclosure to the Department, the Department of Human Services, and to any person acting for the Department in the In-Home Telemonitoring for Veterans Initiative, of telemonitoring initiative data in relation to the person.
 
Note: the participating LMO is to obtain the consent and keep evidence of it.
 
6B.2.2 Where a person is eligible for participation in the In-Home Telemonitoring for Veterans Initiative (eligible person), it is necessary for the eligible person’s participation to be approved by the Commission.
 
Note: in practice a Commission delegate may grant approval.
 
6B.2.3 Where the Commission gives (or does not give) its approval it is to notify the participating LMO for the eligible person accordingly.
 
6B.2.4 Upon being notified of the Commission’s approval, the participating LMO for the person is to enrol the person in the In-Home Telemonitoring for Veterans Initiative.
 
6B.2.5 Enrolment consists of the participating LMO for the person making a record (which may be in electronic form) that the person is enrolled in the In-Home Telemonitoring for Veterans Initiative.
 
6B.2.6 The record is to be dated and stored by the participating LMO.  The date on the record is the enrolment day for the relevant telemonitoring initiative participant.
 
6B.3  Approval of LMO as Participating LMO
 
6B.3.1 The Commission may approve an LMO as a participating LMO if:
 
(a) the LMO’s name is given as a participating GP in the form: “Application for Practice and Provider registration to In-Home Telemonitoring for Veterans Initiative” lodged with the Department of Human Services; and
 
(b) in the Commission’s opinion, all necessary steps have been taken to enable the LMO (and a Practice Nurse of the LMO) to effectively participate in the In-Home Telemonitoring for Veterans Initiative such as appropriate training and installation of any necessary telemonitoring equipment.
 
6B.4 Payment for telemonitoring treatment
 
6B.4.1 If the Commission arranges with a participating LMO for the LMO (or the LMO’s Practice Nurse) to provide the telemonitoring treatment described in 6B.1.2(a) to an entitled person who is eligible for the treatment under this Part, the terms of payment to the LMO for the treatment are set out in the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services”.
 
Note 1: payments to participating LMOs for providing telemonitoring treatment for a person are in addition to any payments to the LMO for the LMO (or the LMO’s Practice Nurse) providing treatment to the person under the Coordinated Veterans’ Care Program or for the LMO providing consultations to the person (including teleconsultations) other than pursuant to a telemonitoring care plan.
 
Note 2: payments to participating LMOs for providing telemonitoring treatment will be comprised of a DVA Telemonitoring Practice Incentive (made to the LMO’s Practice) and other relevant payments (general payments) as set out in the Department of Veterans’ Affairs Fee Schedules for Medical Services. 
 
Note 3: the general payments for telemonitoring treatment (i.e. exclusive of the DVA Telemonitoring Practice Incentive ) will be made on the similar basis as payments to LMOs under the Coordinated Veterans’ Care Program i.e. quarterly payments in arrears.
 
6B.4.2 An Authorised Representative for the Practice in which a participating LMO is employed (the LMO) is only to be paid a DVA Telemonitoring Practice Incentive if the Commission is of the opinion that all necessary steps have been taken to enable the LMO (including a Practice Nurse of the LMO) to effectively participate in the In-Home Telemonitoring for Veterans Initiative.
 
6B.4.3 If the Commission arranges with a person (data repository controller) for the person to provide the telemonitoring treatment described in 6B.1.2(b) to an entitled person who is eligible for the treatment under this Part (or to a person on the entitled person’s behalf) or to a participating LMO, the terms of payment to the person are those agreed to by the Department and the person.
 
6B.4.4 If the Commission arranges with a person (trainer in data evaluation) for the person to provide the telemonitoring treatment described in 6B.1.2(c) to a participating LMO or to a participating LMO and the LMO’s Practice Nurse, the terms of payment to the person are those agreed to by the Department and the person.
 
6B.4.5 If the Commission arranges with an ISP provider to provide the telemonitoring treatment described in 6B.1.2(d) to an entitled person who is eligible for the treatment under this Part, the Department will pay the reasonable costs of such treatment for the duration of the entitled person’s participation in the In-Home Telemonitoring for Veterans Initiative where the treatment is provided to the person on or after the enrolment day for the person.
 
Note: the cost of an NBN connection for an entitled person will only be paid by the Department to an ISP provider and only for a connection on or after the enrolment day for the entitled person in the In-Home Telemonitoring for Veterans’ Initiative.
 
6B.5  Coordinated Veterans’ Care Program Rules to Apply
 
6B.5.1 Subject to 6B.5.2, the rules in the DVA document entitled “Notes for Coordinated Veterans' Care Program Providers” are to apply to participating LMO’s and telemonitoring initiative participants to the extent practical as if participating LMO’s and telemonitoring initiative participants under the In-Home Telemonitoring for Veterans Initiative, are, respectively, LMOs and entitled persons under the Coordinated Veterans’ Care Program.
 
Note: the rules would include those governing patient transfers between participating LMOs.
 
6B.5.2 In the application of the Notes for Coordinated Veterans' Care Program Providers to a participating LMO under the In-Home Telemonitoring for Veterans Initiative, the date of service for a quarterly period in respect of telemonitoring treatment provided by a participating LMO to an entitled person is taken to be the most recent date of service for a quarterly period in respect of which the LMO provided LMO Care Leadership treatment to the entitled person.
 
Note (1) Under the Notes for Coordinated Veterans' Care Program Providers the "date of service for the quarterly period" is the first day of the quarterly period.
 
Note (2): the purpose of 6B.5.2 is to align, for billing purposes, the date of service for a quarterly period in respect of telemonitoring treatment provided by an LMO to an entitled person (i.e. the first day of the period) with the date of service for a quarterly period in respect of LMO Care Leadership treatment (Coordinated Veterans' Care Program treatment) provided by the LMO to the entitled person despite the telemonitoring treatment not actually being provided on that date. Telemonitoring treatment may only be provided to an entitled person who is also receiving Coordinated Veterans' Care Program treatment.
 
6B.6  Authorised Representative - Agent of LMO
 
6B.6.1 For the purpose of:
 
(a) the Commission arranging telemonitoring treatment with a participating LMO or the LMOs Practice Nurse or for taking action incidental thereto;
 
(b) the Department or the Department of Human Services making payments to the participating LMO (including for the services of the LMOs Practice Nurse) or for taking action incidental thereto;
 
if the Commission, the Department or the Department of Human Services, as the case may be, deals with the Authorised Representative for the Practice in which the participating LMO and Practice Nurse is employed, then for the purposes of these Principles the Commission, the Department or the Department of Human Services is taken to have dealt with the participating LMO (including the LMO’s Practice Nurse).
 
 
 
PART 7 — TREATMENT GENERALLY FROM OTHER HEALTH PROVIDERS
7.1     Prior approval and financial responsibility for health services
 
7.1.1  Except where provided in:
 
(1)     the Principles;
(2)     the Notes for Allied Health Providers; or
(3)     a Fee Schedule;
 
the Commission’s prior approval for a treatment under this Part is not required.
 
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;
 
(c)    chiropractic services;
 
(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 be taken to have arranged 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 or with the VVCS OPC Provider Notes, as the case may be, for that item in Column B below:
 
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 (except where providing service as outreach program counsellors)

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 (except where providing service as outreach program counsellors)

Section 2(a) – Allied Mental Health Care Providers

15
Social Workers (General) (except where providing service as outreach program counsellors)

Section 2(a) – Allied Mental Health Care Providers

16
Social Workers (Mental Health) (except where providing service as outreach program counsellors)

Section 2(a) – Allied Mental Health Care Providers

17
Speech Pathologists

Section 2(l) – Speech Pathologists

 
 
VVCS OPC Provider Notes
 

18
Outreach Program Counsellor
VVCS OPC Provider Notes

 
 
 
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, a treating doctor in a hospital, a hospital discharge planner, an authorised nurse practitioner, or a 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.3A      Dual Services
 
(1) If, under section 214 of the Act, the Commonwealth is liable to pay weekly compensation for household services provided to a person, the person is not entitled to Domestic Assistance or Home and Garden Maintenance.
 
(2) If, under section 217 of the Act, the Commonwealth is liable to pay weekly compensation for attendant care services provided to a person, the person is not entitled to Personal Care.
 
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
(c)        in the case of a Home Care service (category B) — provide the service.
 
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
(c)          the provision of a Home Care service (category C) to an entitled person by an approved provider;
 
is not required except that in the case of the provision of a Home Care service (category A) to an entitled person by an approved provider that is emergency short term home relief (ESTHR), the prior approval of the Commission is required for the provision of ESTHR within 24 hours after a previous service of ESTHR.
 
Note: the fact that the Commission's prior approval for treatment is not required does not mean an assessment is not required.
 
 
Limited MHC-type services for dependants and former dependants
                            
7.3A.19A    Definitions
 
For the purposes of paragraphs 7.3A.19A to 7.3A.22 (inclusive):
 
eligible person means a person who is eligible for a service.
service means a limited MHC-type service.
 
7.3A.19 Subject to paragraph 7.3A.21, the Commission may accept financial responsibility for the provision of a limited MHC-type service to a person eligible to receive the service.
                           
7.3A.20      A person eligible for a limited MHC-type service is a person who the Commission decides is:
 
(a) a former partner who was a dependant of a deceased entitled member ¾ in circumstances where the deceased entitled member was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both; or
 
        (b) an eligible young person who was a dependant of a deceased entitled member ¾ in circumstances where the deceased entitled member was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both; or
 
(c)  a former eligible young person who was a dependant of a deceased entitled member ¾ in circumstances where the deceased entitled member was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both and the former eligible young person is a person with a serious disability; or
 
(d) a former eligible young person who was a dependant of a deceased entitled member ¾ in circumstances where the deceased entitled member was, at or about the time of death, being provided with Domestic Assistance or Home and Garden Maintenance or both and the former eligible young person was a full-time carer of the deceased entitled member immediately prior to the death of the entitled member; or
 
(e)  the partner of an entitled member ¾ who resided with that member immediately before the member needed to leave the home in order to receive treatment, and at or about the time of the member's departure the member was being provided with Domestic Assistance or Home and Garden Maintenance or both; or
 
(f) either: (i) an eligible young person who is a dependant of an entitled member; or
                        (ii) a former eligible young person who is a dependant of an
                             entitled member;
 
who resided with the entitled member immediately before the entitled member needed to leave the home in order to receive treatment and at or about the time of the departure of the entitled member:
 
(iii) the entitled member was being provided with Domestic Assistance or Home and Garden Maintenance or both; and
        
(iv) in the case of a former eligible young person who is a dependant of an entitled member and who is residing with the member ¾ the former eligible young person is a person with a serious disability or was the full-time carer of the entitled member.
 
7.3A.21 The conditions on which the Commission will accept financial responsibility for the provision of a limited MHC-type service to a person eligible to receive the service are:
 
(1) in respect of an eligible person in paragraph 7.3A.20 (a) — the service is provided for a period of no longer than 12 weeks commencing on the day after the day on which the entitled member died ("commencement day"), unless, within the period of 12 weeks commencing on the commencement day, the person makes a claim for compensation under section 319 of the Act in which case the service is provided for no longer than the period commencing on the commencement day and ending at the end of the day on which the Commission determines the claim.
 
Note (1): in practice a Commission delegate will determine a claim and the Department will communicate details of the determination to the delegate of the Commission who arranged provision of the limited MHC-type service.
 
Note (2): in practice the Commission will be a delegate exercising the Commission's assessment powers.
 
(2) in respect of an eligible person in paragraphs 7.3A.20 (e) or (f), the service is provided over a period no longer than 12 consecutive weeks commencing on the day the entitled member left the home for treatment.
 
(3) the service is identical to either Domestic Assistance or Home and Garden Maintenance (or both) that the relevant entitled member was receiving at or about the time of his or her death or at or about the time of his or her departure from the home for treatment, as the case may be.
 
(4) the service is provided on the same terms, including any liability to make a co payment, that the Domestic Assistance or Home and Garden Maintenance (or both) was provided to the relevant entitled member at or about the time of his or her death or at or about the time of his or her departure from the home for treatment, as the case may be.
 
(5) the eligible person resided in the home of the relevant entitled member at the time of the death of the relevant entitled member or at the time the relevant entitled member departed from the home for treatment, as the case may be.
 
(6) in order for an eligible person referred to in paragraph 7.3A.20 (d) to be provided with a service, the eligible person must have been the full-time carer of the entitled member immediately prior to the death of the member at or about the time the service is required.
 
7.3A.22 For the purposes of paragraph 7.3A.21, a particular entitled member is a "relevant entitled member" in relation to a particular eligible person, where the eligible person was residing with that member at the time of the death of the member or at the time of the departure of the member from the home for treatment, and the eligible person is relying on that fact as constituting an element necessary to establish the basis for the person's entitlement to a service.
                         
Note (1): the intention is to ensure that the conditions for providing a service to an eligible person are related to that person's particular circumstances.  For example, a former eligible young person who resided with an entitled member before his/her death is only entitled to the domestic-type assistance that member was receiving and is not entitled to the domestic-type assistance some other entitled member was receiving. 
 
Similarly, a former eligible young person is not entitled to Home and Garden-type maintenance if the relevant entitled member had not been receiving Home and Garden Maintenance.  The entitlement of the eligible person is to reflect the entitlement of the primary beneficiary ie the entitled member.
                         
7.4     Optometrical services
7.4.1  The Commission 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
 
(c)     the DVA document entitled “Pricing Schedule for Visual Aids”, in force on the date in Schedule 1.
 
 
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; or
 
          (b)     where those services are to be provided in a public hospital.
 
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 an entitled person given a high level of residential care in a residential care facility;
 
(b)              where those services are to be provided in a public hospital;
 
(c)              when prescribing temporary footwear, prescribing more than two pairs of medical grade footwear;
 
(d)             prescribing more than three pairs for entitled persons living in remote areas;
 
(e)               repairing depth and custom footwear if the cost is over $100;
 
(f)                modifying depth and custom footwear if the cost is over $100;
 
(g)              providing an Electrodynographic Analysis and Report;
 
(h)             providing a Video Gait Analysis and/or Treadmill Analysis and Report;
 
(i)                delivering services valued at over $60 under the Miscellaneous Items listed in the Deed of Agreement between the Commission and the podiatrist.
 
7.6.3  The Commission will accept financial responsibility for surgical removal of the toenail plate (either partial or total) by a registered podiatrist 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
 
(c)      provided by a supplier approved by the Commission.
 
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
 
(c) the diabetes educator has a provider number.
 
7.6A.2 Prior approval is required for diabetes educator services where:
 
(a)  those services are to be provided to an entitled person given a high level of residential care in a residential 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.
 
7.7A                 Outreach Program Counselling
        
7.7A.1 The treatment of outreach program counselling is established under this Part and may be provided by an outreach program counsellor to an eligible entitled person in accordance with the Principles.
 
Note: paragraph 7.1A.1 requires outreach program counselling to be provided in accordance with the VVCS OPC Provider Notes.
 
7.7A.2 An entitled person is eligible for outreach program counselling if:
 
(a) the entitled person is eligible for VVCS; and
 
Note: see paragraph 7.7A.3
 
(b) in the opinion of the Commission:
 
(i) the entitled person is unable to reasonably have access to a VVCS Centre due to the physical isolation of the person’s place of residence in Australia; or
 
(ii) despite the entitled person having reasonable access to a VVCS Centre, there is a special reason for the person requiring outreach program counselling; and
 
(c) the outreach program counselling is provided to the entitled person by an outreach program counsellor pursuant to a referral from the Veterans and Veterans Families Counselling Service.
 
7.7A.3 An entitled person is eligible for VVCS if he or she satisfies a VVCS criterion.
 
7.7A.4 For paragraph 7.1.1, prior approval for outreach program counselling is not required.
 
7.8     Other services
 
7.8.1  The Commission will not accept financial responsibility for certain services, including:
 
(a)   herbalist services;
 
(b)   homeopathy;
 
(c)    iridology;
 
(d)   massage that is not performed as part of authorised physiotherapy, chiropractic or osteopathy services; and
 
(e)    naturopathy.
 
 
 
PART 9 — TREATMENT OF ENTITLED PERSONS AT HOSPITALS AND INSTITUTIONS
9.1     Admission to a hospital or institution
9.1.1  Subject to these Principles, the Commission will accept financial responsibility for the provision of treatment to entitled persons at a hospital or an institution.
 
9.1.2  The Commission will not approve, or accept financial responsibility for, admission to a hospital or an institution if:
 
(b)   the person could have been provided with suitable outpatient treatment; or
 
(c)    the person could have been suitably cared for at home, with or without supporting community health care services, unless the admission would provide respite for a carer of an entitled person.
 
9.1.3  Notwithstanding other provisions of these Principles, the Commission will accept financial responsibility for the emergency admission to the nearest hospital of an entitled person for treatment if an office of the Department is notified on the first working day after the admission, or as soon thereafter as is reasonably practicable if that admission is to a private hospital requiring prior approval as set out in Part 3 of these Principles.
 
9.1.4  Where hospital treatment of an entitled person has been arranged under these Principles, and the person’s partner is an inpatient at another hospital within reasonable proximity, the Commission may arrange the admission or transfer of the person to the hospital at which the person’s partner is an inpatient.
 
9.1.5  If such arrangements are made under paragraph 9.1.4, the Commission will accept financial responsibility for the hospital treatment of the entitled person.
 
9.1.6  The Commission will accept financial responsibility for the admission of an entitled person to a Tier 2 or Tier 3 hospital, as set out in Principle 2 of the MPPPs, only if prior approval for the admission is obtained.
 
9.1.7  When giving consideration of prior approval under paragraph 9.1.6, the Commission will have regard to the matters set out in paragraph 3.2.2 and in Principle 2 of the MPPPs.
 
9.1.8  Subject to this Part, the Commission will accept financial responsibility for inpatient treatment of an entitled person in a country or a Territory public hospital or in a private hospital with which arrangements have been previously agreed with the Commission and according to the preferences and requirements set out in Part 3 of these Principles and in Principle 2 of the RPPPs.
 
9.1.9  The Commission’s approval is required before it will accept financial responsibility for the admission to hospital, or for hospital treatment, of entitled persons in all other circumstances.
 
9.1.10         Where prior approval is required, the Commission will not accept financial responsibility for any additional charges where an admission for treatment is arranged according to these Principles and then non-Medicare Benefits Schedule surgery or cosmetic surgery is performed subsequently without the Commission's approval.
 
9.2     Financial Responsibility For Treatment In Hospital
9.2.1  Subject to paragraph 9.2.5, the Commission will accept financial responsibility for any usual and reasonable hospital treatment that takes place at the hospital for persons admitted in accordance with these Principles.
 
9.2.2  The Commission may accept financial responsibility for any usual and reasonable treatment that takes place outside the hospital if it is prescribed as a necessary part of inpatient treatment.
 
9.2.4  Subject to paragraph 9.2.5, the Commission will accept financial responsibility for hospital charges on the basis of:
 
(a)   for a public hospital — an amount in accordance with arrangements made with the appropriate State/Territory authority; or
 
(b)   for a contracted private hospital — the rate agreed between the Commission and the hospital; or
 
(c)    for a non-contracted private hospital, when neither a public nor a contracted private hospital can provide the treatment required — the rate agreed from time to time between the Commission and the hospital; or
 
(d)   for a non-contracted hospital, when chosen by an entitled person in preference to a contracted private hospital — a rate to be determined by the Commission.
 
9.2.5  The Commission will not accept financial responsibility for the whole, or that portion, of:
 
(a)   hospital charges; or
 
(b)   charges for any surgically implanted prostheses; or
 
(c)    charges paid by health fund benefits,
 
in circumstances where the entitled person:
 
(d)   is insured by private health insurance for hospital charges or surgically implanted prostheses; and
 
(e)    agrees to assign to the hospital or other institution the benefits available from private health insurance in respect of all or part of the hospital charges or surgically implanted prostheses.
 
9.3     Nursing-home-type care
9.3.1  Where:
 
(a)   an entitled person remains an inpatient in excess of 35 consecutive days and there is no acute care certificate under section 3B of the Health Insurance Act 1973 in force stating reasons approved by the Commission for the continuing need for acute care; or
 
(b)   the medical practitioner responsible for treating the entitled person agrees at any time after admission that the entitled person no longer requires acute care;
 
the person will be regarded as receiving nursing-home-type care.
 
9.3.2  If an entitled person:
 
(a)     is eligible for a residential care subsidy under the Aged Care Act 1997; and
         
(b)     is receiving nursing-home-type care as defined in paragraph
                    9.3.1;
 
the Commission will accept financial responsibility for the standard hospital fee for nursing-home-type patients under the National Health Act 1973, or other agreed fee, less the residential care amount, unless:
 
(c)      the Commission has granted an exemption under paragraph 10.2.1;
             
in which case the Commission will accept financial responsibility for the full amount of the hospital charge.
 
9.3.3  Nothing in this Part is to be taken to permit payments to be made by the Commonwealth under both the Act and either the Aged Care Act 1997 or the National Health Act 1953 in respect of the same amount for which the Commonwealth has become liable in respect of nursing-home-type care under these Principles or the Aged Care Act 1997 or the National Health Act 1953.
 
9.5     Convalescent care
9.5.1  Subject to prior approval and subject to paragraph 9.2.5, the Commission will accept financial responsibility for the costs of convalescent care for an entitled person at an institution for a maximum of 21 days during any financial year.
 
9.6     Other matters
9.6.1  The Commission may withdraw its approval, at any time, for an entitled person’s continued inpatient treatment in a hospital or other institution.
 
PART 10 — RESIDENTIAL CARE, HOME CARE 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 1997 and the Principles.
 
10.1.3  Upon the Commonwealth becoming liable to pay an amount under the Aged Care Act 1997 (e.g. veterans’ supplement) 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 (which would include the veterans’ supplement) 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 1997.
 
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 1997 (Principles) are made under subsection 96-1 (1) of the Aged Care Act 1997.  Under Part 7 of the Principles the Secretary may increase the number of days a person may be provided with residential care as respite care by 21.
 
 
LIMITS OF FINANCIAL RESPONSIBILITY ACCEPTED BY THE COMMISSION FOR RESPITE ADMISSION
 
category of patient
 
type of care; max.period of care permitted; type of care costs accepted
type of care; max.period of care permitted; type of care costs accepted
 

 
 
 
 
 
 
 
residential care (28 day respite)
 
 
up to 28 days (inclusive) in a Financial year
 
residential care (respite) other than residential care (28 day respite)
 
upon an entitled person exhausting 28 days of residential care (28 day respite) in a Financial 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 (including any veterans’ supplement).
 
‘RCS + RCA’ means the Commission will accept financial responsibility for the residential care subsidy (including any veterans’ supplement) and the residential care amount.
 
* or for such further period permitted under the Residential Care Subsidy Principles 1997.
 
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 1997; 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 1997).
 
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 1997) 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 10.3.9 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 – HOME CARE
 
Definition:
 
“co-payment” means an amount a person must pay for home care but does not include an amount payable to the provider of the home care as subsidy under the Aged Care Act 1997.
 
10.5   The Commission may accept financial responsibility for the co-payment a former prisoner of war, or an entitled member awarded the Victoria Cross for Australia (VC veteran), paid, or is to pay, for home care for the person pursuant to an agreement with the provider of the home care — 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.
 
10.6   In deciding whether to accept financial responsibility for a co-payment for home care 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).
 
10.7            Billing
 
10.7.1         The provider of a service of home care should bill the Department of Human Services for the co-payment rather than the former prisoner of war or VC recipient (client) but if the client is billed, the Commission may, subject to paragraph 10.5 and 10.6, accept financial responsibility for the co-payment.
 
Part E – TRANSITION CARE CO-PAYMENT
 
“co-payment” means an amount a person must pay for transition care but does not include an amount payable to the provider of the transition care as subsidy under the Aged Care Act 1997.
 
 
10.8   Financial Responsibility for Co-Payment
 
10.8.1         The Commission may accept financial responsibility for the co-payment an entitled member who is former prisoner of war (POW), or an entitled member awarded the Victoria Cross for Australia (VC recipient), paid, or is to pay, to an approved provider for transition care provided to the person:
 
(a) 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, in force from time to time; and
 
Note (1): as at December 2010 the maximum number of days for which flexible care subsidy was payable for transition care was 126 days.
 
Note (2): as at 1 July 2013 there was a proposal to consolidate the various legislative instruments under the Aged Care Act 1997 in one set of Subsidy Principles.  If that occurs, the intention is that the new Subsidy Principles as they relate to flexible care will be the Flexible Care Subsidy Principles 1997 as in force from time to time.
 
(b) to the extent:
 
 
          (i)      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
 
(ii)     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.
 
10.8.2                                      In deciding whether to accept financial responsibility for a co-payment 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).
 
10.9            Billing
 
10.9.1         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 10.8.1 and 10.8.2, 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)   a surgical appliance; and
(b)   an appliance for self-help and rehabilitation purposes;
 
to an entitled person, for an injury or disease of the person, unless the appliance could be provided to the person, for that injury or disease, by the Commission under a Part of the Act, other than Part 3 of Chapter 6 of the Act, or under SRCA.
 
Note (1): an appliance 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 and could be provided under Part III or s.148 of SRCA (but not under s.16(1) by virtue of s.144B(5) SRCA).
 
Note (2): the Commission providing an appliance means the Commission arranges for its provision or accepts financial responsibility for the cost of the appliance where its provision is arranged by a third party.
 
Note (3): 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
 
(c)    towards meeting health care objectives; and
 
(d)   in a cost effective manner; and
 
(e)    on a timely basis.
 
11.1.4 An appliance that is provided should be:
 
(a)   appropriate for its purpose; and
 
(b)   safe for the particular entitled beneficiary; and
 
(c)    part of the overall management of health care for the entitled person;
 
but should not be an item that is customarily used for domestic purposes and would be used merely for such a purpose by the entitled person.
 
11.2   Supply of rehabilitation appliances
11.2.1 Unless otherwise indicated in these Principles, the Commission will arrange the supply of rehabilitation appliances on the condition that these are returned when no longer needed or if the Commission so requests.
 
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
 
(c)    who has been assessed by the Commission as being able to benefit from use of the electronic communication equipment.
 
11.3.4 For the purposes of paragraph 11.3.2, a severely handicapped entitled member means an entitled member:
 
(a)   whose severe handicap was a service injury or service disease; and
 
(b)  who has a medically assessed need for the electronic communication equipment; and
 
(c)   who has been assessed by the Commission as being able to benefit from the use of the equipment because it would substantially improve the member's:
 
(i)   communication skills; and
 
(ii)  quality of life.
 
11.3.6                   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 a cluster of self-care units.
 
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 a cluster of self-care units.
 
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
 
(c)   for a program, it is more appropriate that the appliance is provided under the program because:
 
(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.
 
              (c) the rehabilitation appliance is not a consumable
rehabilitation appliance.
 
Note (1): “institution” includes a retirement village, premises the Commission considers have similar functions to a retirement village, and a cluster of self-care units.
 
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
 
(c)      the DVA document entitled “Pricing Schedule for Visual Aids”, in force on the date in Schedule 1.
 
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
 
(c)    the MRCA Pharmaceutical Benefits Scheme.
 
11.6.5 The Commission will accept financial responsibility for the cost of membership of a stoma association and for the cost of postage of stoma supplies.
 
11.7   Repair and replacement
11.7.1 The Commission may approve the provision of more than one of the same rehabilitation appliance if the entitled person depends completely on the appliance, and:
 
(a)   it is necessary to maintain the appliance in a hygienic condition because of domestic or occupational circumstances; or
 
(b)   the entitled person lives in an isolated country area and would be handicapped by loss or breakage; or
 
(c)    there are other circumstances where the Commission considers it reasonable to do so.
 
11.7.2 Subject to paragraphs 11.7.6 and 11.7.7, the Commission will not be financially responsible for the alteration to, or the repair of, a treatment aid without prior approval.
 
11.7.3 The Commission will not be financially responsible for, or reimburse, the cost of an alteration to, or a repair of, a rehabilitation appliance for which it has not accepted financial responsibility, unless there are circumstances where the Commission considers it reasonable to accept financial responsibility.
 
11.7.4 The Commission will not be financially responsible for repair or replacement of a rehabilitation appliance for a non service injury or disease injury or disease while an entitled person is travelling overseas.
 
11.7.5 Prior approval will be given for the repair or replacement of an appliance where repair or renewal is necessary because:
 
(a)   the appliance was damaged by normal wear and tear;
 
(b)   the appliance inadvertently was damaged or lost; or
 
(c)    the health-care practitioner treating the entitled person considers that a replacement is required because the person’s condition has changed.
 
11.7.6 The Commission will not give approval for the repair or replacement of an appliance if repair or renewal is necessary as the result of:
 
(a)     a wilful act of the entitled person using or wearing the appliance; or
 
(b)     a negligent act of the entitled person using or wearing the appliance and the person has damaged or lost a similar appliance in the past as a result of negligence or wilfulness.
 
11.7.7 Prior approval is not required for repairs to spectacles.
 
11.8   Treatment aids from hospitals
11.8.1 The Commission may provide, or accept financial responsibility for, treatment aids as part of inpatient treatment where the aids expedite discharge from hospital.
 
11.8.2 The conditions for the supply of treatment aids are the same as those normally applied by the hospitals for patients not covered by these Principles.
 
11.8.3         The Commission will not provide, or accept financial responsibility for, a treatment aid as part of inpatient or outpatient treatment where the treatment solely comprises the provision of the treatment aid.
 
11.9   Provision of aids and appliances for accident prevention and personal safety
11.9.1     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 revoked MRCA Treatment Principles before the commencement of the MRCA Treatment Principles (Instrument 2013 No. MRCC 53) (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 MRCA Treatment Principles (Instrument 2013 No. MRCC 53) 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
 
(c)     is safe and appropriate for the person’s particular circumstances; and
 
(d)     is customarily used for domestic purposes and would be used for such purposes by the person; and
 
(e)     would be provided or installed efficiently, cost effectively, and on a timely basis.
 
11.9.3  The Commission may enter into arrangements with a person or persons:
 
(a)     to provide the Commission with reports from home and safety assessors; and
 
(b)     for the provision of aids and appliances for accident prevention and personal safety.
 
11.9.4  Subject to Principle 3.4, the Commonwealth will not be financially responsible, either partly or wholly, for the purchase, supply, or installation of an aid or appliance for accident prevention and personal safety unless:
 
(a)     financial assistance has been approved under paragraph 11.9.1; and
 
(b)     the appliance is provided under an arrangement entered into under paragraph 11.9.3.
 
11.9.5                   The Commission 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 a cluster of self-care units.
 
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.
 
PART 12 — OTHER TREATMENT MATTERS
12.1   Ambulance transport
12.1.1 With the exception of arrangements for medical emergency under paragraph 12.1.4 and special arrangements under paragraph 12.1.5, prior approval must be obtained in all cases before ambulance transport is used by an entitled person.
 
12.1.2 Approval for ambulance transport normally will be given where the entitled person:
 
(a)   is a stretcher case;or
 
(b)   requires treatment during transport;or
 
(c)    is grossly disfigured; or
 
(d)   is incontinent to a degree that precludes the use of other forms of transport.
 
12.1.3 Other than in exceptional circumstances, air ambulance will be approved only to transport an entitled person with acute medical and surgical complaints for admission to, or discharge from, a hospital.
 
12.1.4 The Commission will accept financial responsibility for the use of ambulance transport in a medical emergency for an entitled person if an office of the Department is notified on the first working day after the ambulance transport is used or as soon thereafter as is reasonably practicable.
 
12.1.5 Prior approval for ambulance transport for entitled persons is not required where the transport is provided under arrangements between the ambulance service provider and the Commission.
 
12.2          Treatment under Medicare Program
12.2.1 Entitled persons may choose to have their treatment arranged through the Department or under a medicare program.
 
12.2.2  Subject to these Principles, entitled persons who are treated under a medicare program may also receive services that are not covered by the MBS at the Commission’s expense.
 
12.2.3 When part or all of the cost of a treatment item has been paid as a medicare benefit, the Commission will not pay for the same professional or ancillary service regardless of the person’s entitlement under the Act.
 
12.4   Prejudicial or unsafe acts or omissions by patients
12.4.1 The Commission may refuse to be financially responsible for, or provide treatment to, or any further treatment to, an entitled person who, by an act or omission, deliberately prejudices his or her own, or a fellow patient’s, treatment or the safety of persons providing treatment.
12.6   Recovery of moneys
12.6.1 Where a payment has been made to any person or body, purportedly as payment for treatment, the Commission may recover (up to the extent that the payment exceeds the amount, if any, that should have been paid to that person or body) any moneys, the payment of which was induced or affected at all by:
 
(a)   any misrepresentation; or
 
(b)   any mistake of fact; or
 
(c)    any mistake of law; or
 
(d)   any other cause.
 
12.6.2 Further to paragraph 12.6.1, the Commission may recover moneys for any excess amounts that should not have been paid to that person or body:
 
(a)   in a single demand; or
 
(b)   by instalments; or
 
(c)   subject to section 317 of the Act, by offsetting moneys for any excess amounts against any later claims for payment by that person or body; or
Note:      Section 317 provides, in effect, that where amounts have been overpaid, the Commission may, if the person agrees, offset money owed against later payments.
 
(d)   by a combination of any of these methods of recovery.
 
12.6.3 Nothing in this principle is to be taken to restrict any other right or action for recovery of moneys.
 
Transitional Provisions
 
 
(1)    MRCA Treatment Principles (2013 No. MRCC 53)
 
(a) any arrangement entered into, or taken to have been entered into, by the Commission or the Department (on behalf of the Commission) with a health provider, under the revoked MRCA Treatment Principles, being an arrangement that is in force immediately before the commencement of these Principles ¾ is taken to have been entered into under these Principles.
 
(b) any action taken (e.g. issue of a notice, grant of approval, giving of a receipt), and any document produced in the course of that action, by the Commission, the Department (on behalf of the Commission), a health provider or an entitled person, under the revoked MRCA Treatment Principles, being action or a document that is in effect or in force immediately before the commencement of these Principles ¾ is deemed, respectively, to have been taken or produced under these Principles.
 
(c) a Scheme (eg Local Medical Officer Scheme, Local Dental Officer Scheme) prepared by the Repatriation Commission under the Treatment Principles under section 90 of the Veterans' Entitlements Act 1986, that is in force immediately before the commencement of these Principles and is referred to in these Principles,  is taken to have been made by the Commission under these Principles.
 
(d) a person who was receiving care under a Community Aged Care Package or Extended Aged Care at Home Package under the revoked MRCA Treatment Principles immediately before the commencement of these Principles, is, on the commencement of these Principles, entitled to a continuation of that care as if it is home care under these Principles.
 
(e) a requirement in a provision under the Principles for a person to hold a qualification (current qualification), being a different qualification required by the provision in the revoked MRCA Treatment Principles (former qualification) in the state the revoked MRCA Treatment Principles existed immediately before the commencement of these Principles under 1.1.4, is satisfied where a person holds a former qualification.
 
Note: under the revoked MRCA Treatment Principles an aboriginal health worker needed to have undertaken an “aboriginal health care course” at an institution recognised by the Department of Health and Ageing but under these Principles the institution must be recognised by the Department of Prime Minister and Cabinet.  The qualification of an aboriginal health worker obtained at an institution recognised by the former Department of Health and Ageing is recognised under these Principles as if the institution had been recognised by the Department of Prime Minister and Cabinet.
 
 
SCHEDULE 1 DATES FOR INCORPORATED DOCUMENTS
 
The date for :
 
          1.       Notes for Local Medical Officers (paragraph 1.4.1);
 
2.       Department of Veterans’ Affairs Fee Schedules for Medical Services (paragraph 3.5.1);
 
3.       Notes for Allied Health Providers (paragraphs 3.5.1 and 7.1A.1);
 
4.       Optometrist Fees for Consultation (paragraph 3.5.1);
 
5.       DVA Schedule of Fees Orthoptists (paragraph 3.5.1);
 
6.       Pricing Schedule for visual aids (paragraph 3.5.1);
 
7.       ...
         
8.       Fee Schedule of Dental Services for Dentists and Dental Specialists (paragraph 3.5.1);
 
9.       Fee Schedule of Dental Services for Dental Prosthetists (paragraph 3.5.1);
 
          10.     Chiropractors Schedule of Fees (paragraph 3.5.1);
 
11.     Diabetes Educators Schedule of Fees (paragraph 3.5.1);
 
12.     Dietitians Schedule of Fees (paragraph 3.5.1);
 
13.     Exercise Physiologists Schedule of Fees (paragraph 3.5.1);
 
14.     Occupational Therapists Schedule of Fees (paragraph 3.5.1);
 
15.     Osteopaths Schedule of Fees (paragraph 3.5.1);
 
16.     Physiotherapists Schedule of Fees (paragraph 3.5.1);
17.     Psychologists Schedule of Fees (paragraph 3.5.1);
 
18.     Podiatrists Schedule of Fees (paragraph 3.5.1);
 
19.     Social Workers Schedule of Fees (paragraph 3.5.1);
 
20.     Clinical Counsellors Schedule of Fees (paragraph 3.5.1);
 
21.     Speech Pathologists Schedule of Fees (paragraph 3.5.1);
 
22.     Australian Government Department of Veterans’ Affairs Classification System and Schedule of Item Numbers and Fees — Community Nursing Services (paragraph 6A.4.2(b));
 
23.     Notes for Coordinated Veterans' Care Program Providers (Part 6A);
 
24.     Rehabilitation Appliances Program (RAP) National Guidelines (paragraph 11.2A.1);
 
25.     RAP National Schedule of Equipment (paragraph 11.2A.1);
 
26.     Veterans and Veterans Families Counselling Services (VVCS) Outreach Program Counsellors (OPC) Provider Notes (paragraph 1.4.1 and 7.1A.1);
 
27.     Veterans and Veterans Families Counselling Service (VVCS) Outreach Program Counsellors (OPC) Schedule of Fees (paragraph 3.5.1);
 
28.     General information about VVCS – Veterans and Veterans   Families Counselling Service (paragraph 1.4.1);
 
29.     Better Access to Psychiatrists, Psychologists & General Practitioners through the Medical Benefits Schedule Initiative
 
http://www.health.gov.au/internet/mentalhealth/publishing.nsf/Content/better-access-through-mbs-1;
 
is 1 November 2013.