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Military Rehabilitation and Compensation Act 2004                              Section 286 MRCA PRIVATE PATIENT PRINCIPLES Instrument No. M17 of 2004
Dated this      6th       day of     December     2004
     
_______________________ MARK SULLIVAN CHAIR
___________________ IAN CAMPBELL MEMBER
_____________________ SIMON HARRINGTON MEMBER
  _______________________ BARBARA BENNETT MEMBER
 
  _____________________ BRIAN ADAMS MEMBER
          Contents   1.           Preliminary................................................................. 1 1.1      Principles.......................................................... 1 1.2      Defined terms.................................................... 1 Act................................................................. 1 admission........................................................ 1 carerCommission......................................... 1 contracted private hospital............................... 1 country area.................................................... 1 Department..................................................... 1 emergency....................................................... 1 entitled person................................................. 1 facility fee........................................................ 1 Local Medical Officer...................................... 1 medical specialist............................................. 1                                prior approval......................................           2 private hospital................................................ 2 private patient.................................................. 2 veteran partnering private hospital.................... 3 1.3      Private patient status.......................................... 3 2.           Order of preference for admission to hospital.. 1 2.1      Order of preference........................................... 1 2.2      Objective.......................................................... 1 3.           Prior approval not required................................... 2 3.1      Medical specialist treatment............................... 2 3.2      Non-emergency Tier 1 hospital treatment........... 2 3.3.     Non-emergency Tier 2 hospital treatment........... 2 3.4.     Emergency hospital treatment............................. 2 3.5      Notification of admission.................................... 2 3.7      Payment of facility fee........................................ 3 4.           Prior approval required........................................... 3 4.1      Tier 2 hospital admission and treatment.............. 3 4.2      Tier 3 hospital admission and treatment.............. 3 4.3      Criteria for Tier 2 or Tier 3 hospital admission and treatment 3 4.4      Admission to Tier 3 hospital of choice................ 4 4.5      Commonwealth liability if Tier 3 admission by choice 1 5.           Transitional provisions........................................... 1 5.1.1   Past actions....................................................... 1 5.2.1   Application........................................................ 1  

1.     Preliminary      

1.1       Principles and commencement
1.1.1 These Principles are the MRCA Private Patient Principles 2004.   1.1.2 The MRCA Private Patient Principles 2004 commence on 1 January 2005 after the commencement of the Military Rehabilitation and Compensation Treatment (Revocation) Determination Instrument No. M20 of 2004.N>
1.2       Defined terms
For the purposes of these Principles, unless a contrary intention appears:
Act
Act means the Military Rehabilitation and Compensation Act 2004 in force from time to time.
admission
admission means admission for treatment as an in-patient or day-patient upon the referral of a medical specialist or a Local Medical Officer.  
Commission means the Military Rehabilitation and Compensation Commission established under section 361 of the Act.
pensable patient
 
contracted private hospital
contracted private hospital means a private hospital in respect of which the Commission has entered into arrangements under section 285 of the Act for the treatment of entitled persons.
country area

partment
Department means the Australian Government Department of Veterans’ Affairs.
rgency
emergency means a situation in which a person requires immediate treatment because of a serious threat to the person’s life or health.
entitled person
entitled person means a person entitled to treatment under Part 3 of Chapter 6 of the Act
facility fee
facility fee means a fee relating to accident and emergency services charged by a particular hospital.
Local Medical Officer
former Repatriation Hospital means a hospital or other institution that was formerly operated by the Repatriation Commission under paragraph 89(1)(a) of the Veterans’ Entitlements Act 1986.             Note:  see the Repatriation Institutions (Transfer) Act 1992   Local Medical Officer means a private medical practitioner who provides medical treatment to entitled persons under arrangements entered into with the Commission or the Department.
medical specialist
medical specialist means a medical practitioner who is recognised as a consultant physician or specialist in the appropriate specialty for the purposes of the Health Insurance Act 1973. MRCA Treatment Principles means the determination by the Commission under paragraph 286(1)(a) of the Act that sets out the circumstances in which, and conditions subject to which, treatment may be provided to entitled persons.     Principles means the current MRCA Private Patient Principles determined by the Commission under paragraph 286(1)(b) of the Act that sets out, among other things, the circumstances in which treatment may be provided to entitled persons as private patients.
Medicare Benefits Scheduleior approval
prior approval means:   (a)      in relation to treatment—approval by the Commission for treatment before the treatment was given or commenced to be given; and   (b)      in relation to admission to a hospital—approval by the Commission for admission to that hospital before the person is admitted.
private hospital
private hospital means premises that have been declared to be:   (a)      a private hospital for the purposes of the Health Insurance Act 1973; or   (b)      a day hospital facility for the purposes of the National Health Act 1953.
private patient
private patient has the meaning given by subsection 286(7) of the Act. public hospital means a hospital operated by a State or Territory or by the Commonwealth. Repatriation Commission means the body continued in existence by section 179 of the Veterans’ Entitlements Act 1986. Repatriation Private Patient Principles means the principles determined by the Repatriation Commission under section 90A of the Veterans’ Entitlements Act 1986.teran partnering hospital veteran partnering private hospital means a contracted private hospital that is described as a “veteran partnering private hospital” in its arrangement with the Commission. Note:      other Tier 1 status hospitals which have similar partnering arrangements are public hospitals and former Repatriation Hospitals.  
1.3       Private patient status
An entitled person is to receive hospital care as a private patient, which entitles the person, as a minimum, to:   (a)      the patient’s choice of doctor, subject to the doctor having practising rights at the relevant hospital; and   (b)      shared accommodation; and (c)            if medically necessary, private accommodation.  
 
2.     Order of preference for admission to hospital

2.1       Order of preference
Preference for admission is to be in accordance with the following table:  
Level
Preference
Hospital
Tier 1
first
former Repatriation Hospital, public hospital, or veteran partnering private hospital
Tier 2 (special authorisation)
second
The Contracted private hospital is not required to seek prior approval for a referral for services specified in the contract, chargeable to DVA, from a Tier 1 hospital.  The Contracted private hospital must seek prior approval for all other admissions.
Tier 2
second
Contracted private hospital
Tier 3
third
Non-Contracted private hospital
 
2.2       Objective        
The main objective of these Principles is to provide an entitled person with access to the nearest suitable hospital.
3.     Prior approval not required

3.1       Medical specialist treatment
A medical specialist or Local Medical Officer may, without prior approval, refer an entitled person to a medical specialist for treatment as a private patient (whether that medical specialist works at a hospital or at consulting room facilities) only if the fee to be charged by that medical specialist for that treatment is no greater than the fee the medical specialist could charge for the treatment pursuant to the MRCA Treatment Principles.
3.2       Non-emergency Tier 1 hospital treatment
An entitled person may be admitted to a Tier 1 hospital for non-emergency treatment without prior approval.
3.3.      Non-emergency Tier 2 hospital treatment
An entitled person may be admitted to a Tier 2 hospital for non-emergency treatment without prior approval only in those circumstances where the arrangements relating to that hospital specifically exclude the need for prior approval.
3.4.      Emergency hospital treatment
An entitled person may be treated at, and admitted through, the accident and emergency centre of a Tier 1, 2, or 3 hospital for emergency treatment without prior approval.
3.5             Notification of admission
If an entitled person is admitted to a Tier 2 or Tier 3 hospital under paragraph 3.4, the hospital must notify the Department of that admission the next working day in the State or Territory in which the admission occurred, or as soon as practicable afterwards.
3.6       Payment of facility fee
The Commonwealth will pay a facility fee relating to treatment of an entitled person at an accident and emergency centre only if the person was not subsequently admitted to the hospital.
4.     Prior approval required

4.1       Tier 2 hospital admission and treatment
Subject to Principle 3, an entitled person may be admitted to, and have continuing treatment in, a Tier 2 hospital only if a suitable Tier 1 hospital is unavailable and prior approval has been obtained for the admission.
4.2       Tier 3 hospital admission and treatment
Subject to paragraph 3.4, an entitled person may be admitted to, and have continuing treatment in, a Tier 3 hospital only if no suitable Tier 1 or Tier 2 hospital is available and prior approval has been obtained.
4.3       Criteria for Tier 2 or Tier 3 hospital admission and treatment
In deciding whether prior approval will be given under paragraph 4.1 or 4.2 for:   (a)      admission to; or   (b)      continued, non-emergency, treatment in; a Tier 2 or Tier 3 hospital, the Commission must consider where the person’s needs can most appropriately be met within a reasonable time, having regard to:   (c)      advice from the person’s treating medical practitioner concerning:   (i)       the injury or disease being treated; and  (ii)       the clinical need for the proposed treatment; and (iii)       the degree of pain or discomfort; and (iv)       the effect on the person’s quality of life (d)     in light of the severity of the entitled person’s clinical condition:   (i)       the waiting time, if any, at that hospital compared with waiting times, if any, at relevant Tier 1 or Tier 2 hospitals, as the case may be; and  (ii)       the distance that the entitled person would have to travel; and   (e)      reasonable control over Commonwealth expenditure; and   (f)       the extent of a clinical need for continuity of care by a particular medical practitioner; and (g)      any other relevant requirement in these Principles or in the Act.
4.4       Admission to Tier 3 hospital of choice
If prior approval has been given for an entitled person to be admitted to a Tier 2 hospital for the purpose of particular treatment, or an entitled person has been admitted for treatment to a Tier 2 hospital in accordance with paragraph 3.3, the person may elect to be admitted to a Tier 3 hospital of his or her choice for that treatment.  
 
4.5       Commonwealth liability if Tier 3 admission by choice
If an entitled person, in accordance with paragraph 4.4, elects to be admitted to a Tier 3 hospital, the Commonwealth will be liable only for:   (a)      accommodation costs; and   (b)      pharmaceutical fees; and   (c)      theatre fees; and   (d)      certain incidental expenses; provided such costs, fees or expenses are, in the Commission’s opinion, reasonable.
5.     Transitional provisions

5.1       Past actions
5.1.1    Any approval given, decision or appointment made, or other thing done under the Repatriation Private Patient Principles applied by the Determination for Providing Treatment (MRCA Instrument No.3 of 2004) is taken to have been given, made, or done for the purposes of, and under, these Principles.
5.2.      Application
5.2.1    From their commencement, these Principles apply to all matters to which the Repatriation Private Patient Principles applied by the Determination for Providing Treatment (MRCA Instrument No.3 of 2004) related.