Treatment Principles (Australian Participants in British Nuclear Tests) 2006

Instrument 2006 No. R30 as amended

made under the

Australian Participants in British Nuclear Tests (Treatment) Act 2006

This compilation was prepared on 4 December 2012 taking into account amendments up to the

Treatment Principles (Australian Participants in British Nuclear Tests) 2006 (Removal of Prior Approval/New Dental Providers) Instrument 2012 (No. R29/2012) (F2012L02321)

Prepared by the Legal Services & Assurance Branch,

Department of Veterans' Affairs, Canberra

Part 1 of 2 Parts

[1] Definitions

In items [1] and [3] of this Instrument:

Treatment Principles means the document known as the “Treatment Principles” and prepared by the Repatriation Commission under section 90 of the Veterans’ Entitlements Act 1986 and incorporated in the Australian Participants in British Nuclear Tests (Treatment) Act 2006 by section 16 of that Act.

Repatriation Commission means the body corporate known as the Repatriation Commission and continued in existence under section 179 of the Veterans’ Entitlements Act 1986.

[2] Commencement

(a) Subject to paragraph (b), this Instrument commences on the day after it is registered on the Federal Register of Legislative Instruments.

(b) The following provisions, substituted by section 5, commence on the commencement of the legislative instrument entitled Veterans’ Entitlements (Treatment Principles - Access to Diabetes Educator Services) Instrument 2006:

(i) definition of “credentialled diabetes educator”;

(ii) definition of “diabetes educator services”;

(iii) paragraph 3.2.1(na);

(iv) paragraph 3.3.2(da);

(v) paragraph 4.8.1(ga);

(vi) paragraph 7.1.2(aa);

(vii) paragraph 7.6A.

[3] Modifications of the Treatment Principles

The Treatment Principles are modified in accordance with Schedule A.

SCHEDULE A

[4]. Title (twice occurring)

at the end, insert:

(Australian Participants in British Nuclear Tests) 2006

Note: the purpose of this provision is to ensure a part of the Treatment Principles as incorporated in the Act is retained to ensure the Treatment Principles are modified and not substituted.

[5]. All provisions other than the title:

substitute:

Australian Government

REPATRIATION COMMISSION

Table of Provisions

PART 1 — INTRODUCTION

1.2 Application of Repatriation Private Patient Principles (Australian Participants in British Nuclear Tests) 2006

1.4 Interpretation

PART 2 — ELIGIBILITY FOR TREATMENT OF MALIGNANT NEOPLASIA

2.1 Treatment for eligible persons in Australia

2.2 Treatment for entitled persons travelling overseas

PART 3 — COMMISSION APPROVAL FOR TREATMENT OF MALIGNANT NEOPLASIA

3.1 Approval for treatment

3.2 Circumstances in which prior approval is required

3.3 Circumstances in which prior approval is not required

3.4 Other retrospective approval

3.5 Financial responsibility

PART 4 — MEDICAL PRACTITIONER SERVICES FOR MALIGNANT NEOPLASIA

4.1 Local Medical Officers / other General Practitioners

4.2 Providers of services

4.3 Financial responsibility

4.3A Disqualified Medical Practitioners

4.4 Referrals

4.5 Referrals by medical specialists

4.7 Referrals: prior approval

4.8 Other matters

PART 5 — DENTAL TREATMENT IN RESPECT OF MALIGNANT NEOPLASIA

5.1 Providers of services

5.2 Financial responsibility

5.2A Disqualified Dental Practitioners

5.3 Eligibility

5.4 Emergency dental treatment

5.6 General anaesthesia

5.7 Prescribing of pharmaceutical benefits by dentists

5.8 Other dental services

PART 6 — PHARMACEUTICAL BENEFITS

6.1 Repatriation Pharmaceutical Benefits Scheme (Australian Participants in British Nuclear Tests) 2006

6.2 Eligibility under the Repatriation Pharmaceutical Benefits Scheme (Australian Participants in British Nuclear Tests) 2006

PART 7 — TREATMENT FROM ALLIED HEALTH PROVIDERS FOR CONDITIONS ASSOCIATED WITH MALIGNANT NEOPLASIA

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

7.4 Optometrical services

7.5 Physiotherapy

7.6 Podiatry

7.6A Diabetes Educator Services

7.7 Chiropractic and osteopathic services

7.8 Other services

PART 9 — TREATMENT OF ENTITLED PERSONS AT HOSPITALS AND INSTITUTIONS FOR MALIGNANT NEOPLASIA

9.1 Admission to a hospital or institution

9.2 Financial responsibility for treatment in Hospital

9.3 Nursing-home - type care for entitled persons with malignant neoplasia

9.5 Convalescent care

9.6 Other matters

PART 10 — RESIDENTIAL CARE FOR ENTITLED PERSONS SUFFERING FROM MALIGNANT NEOPLASIA

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

10.1 Residential care arrangements

10.4 Payment of residential care amount for certain entitled persons

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 TO ENTITLED PERSONS SUFFERING FROM MALIGNANT NEOPLASIA

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 MATTERS RELATING TO TREATMENT OF MALIGNANT NEOPLASIA

12.1 Ambulance transport

12.2 Treatment under Medicare

12.4 Prejudicial or unsafe acts or omissions by patients

12.6 Recovery of moneys

SCHEDULE 1 – DATES FOR INCORPORATED DOCUMENTS

PART 1 — INTRODUCTION

1.1.1 The Treatment Principles (Australian Participants in British Nuclear Tests) 2006 (the Treatment Principles), prepared by the Repatriation Commission under section 16 of the Australian Participants in British Nuclear Tests (Treatment) Act 2006 (the Act), set out the circumstances in which, and conditions subject to which, treatment may be provided for eligible persons under Part 2 of the Act and are to be read subject to the Act.

1.1.2 The Treatment Principles state the policies under which the Repatriation Commission may accept financial responsibility for the cost of treatment of malignant neoplasia for persons eligible for such treatment under the Act.

1.2 Application of Repatriation Private Patient Principles (Australian Participants in British Nuclear Tests) 2006

1.2.1 The Repatriation Private Patient Principles (Australian Participants in British Nuclear Tests) 2006 (the RPPPs), determined by the Commission under subsection 17(2) of the Act, apply in all States in which a Repatriation General Hospital has been integrated into the State health system and in those States and Territories in which the Commission has declared, under section 90B of the Veterans’ Entitlements Act 1986, that the VEA Repatriation Private Patient Principles, made under section 90A of the Veterans’ Entitlements Act 1986, apply.

1.2.2 In those States or Territories where the RPPPs apply, a provision of the Treatment Principles does not apply if it is inconsistent with the RPPPs.

1.2.3 Nothing in these Treatment Principles is to be taken to require prior approval for admission at a public hospital in any State or Territory in which the RPPPs apply.

1.4 Interpretation

1.4.1 In these Treatment Principles, unless a contrary intention appears:

“Act” means the Australian Participants in British Nuclear Tests (Treatment) Act 2006

"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 “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: an 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.

“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.

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

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

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

“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.

“Commission” means the Repatriation 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.

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

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

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

“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 or the Department in respect of treatment provided at the premises to entitled persons;

but does not include any of the following premises:

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

(e) a private hospital;

(f) a nursing home;

(g) a residential rehabilitation establishment.

“contracted private hospital” means a private hospital with which the Commission has entered into arrangements for the purposes of the VEA Treatment Principles or the VEA Repatriation Private Patient Principles for the care and welfare of eligible 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, associated with malignant neoplasia.

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

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

“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

(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.

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

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

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

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

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

“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 credentialled diabetes educator to a person with diabetes.

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

“eligible person” means a person who is eligible for treatment under 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.

“entitled person” means a person who is eligible for treatment under the Act.

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

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

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

and an episode of care arises:

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

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

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.

“Fee Schedule” means a DVA document approved by the Commission or a member thereof, 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.

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

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

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

Note (2): The phrases ‘classification level’ and ‘respite care’ used in this definition are also defined in the Aged Care Act 1997.

Note (3): This definition does not exclude entitled persons in respite care or convalescent care.

“home” includes:

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

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

but does not include:

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

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

“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 is required under the Principles to be approved by the Commission or approved by the Department or approved by either– the document has been approved as required.

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

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

Note: an example being a Fee Schedule (para.1.4.1).

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

“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.

"Level A attendance" means a medical attendance described in an item in Level A, Group A1, Schedule of Services, Category 1-Professional Attendances, General Medical Services, of the Medical Benefits Schedule.

“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.

"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.

“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.

“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.

“minor procedure” means a surgical procedure that:

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

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

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

“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

“neuropsychologist” means a person who:

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

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

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

“Notes for Local Medical Officers” means the document:

(i) approved by the 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 Commission or a member thereof, 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.

“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.

“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.

"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.

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

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

(a) the patient's medical history;

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

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

“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.

“Principles” means the Treatment Principles (Australian Participants in British Nuclear Tests) 2006 made under subsection 16(2) of the Act.

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

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

“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.

"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.

“RAP National Schedule of Equipment” means the document of that name approved by the Commission or a member of 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.

"Rehabilitation Appliances Program (RAP) National Guidelines"

means the document of that name approved by the Commission or a member of 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 known as the Repatriation Commission and continued in existence under section 179 of the Veterans’ Entitlements Act 1986.

"Repatriation Pharmaceutical Benefits Card" means the identification card entitled 'Repatriation Pharmaceutical Benefits Card' which is provided to a person for the purposes of the person obtaining pharmaceutical benefits pursuant to the Repatriation Pharmaceutical Benefits Scheme (Australian Participants in British Nuclear Tests) 2006.

“Repatriation Pharmaceutical Benefits Scheme” means the Repatriation Pharmaceutical Benefits Scheme (Australian Participants in British Nuclear Tests) 2006 made under subsection 18(2) of the Act.

“RPPPs.” means the Repatriation Private Patient Principles (Australian Participants in British Nuclear Tests) 2006 determined by the Commission under section 17(2) of the Act.

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

(a) meals and cleaning services; and

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

provision of that care and accommodation;

but does not include any of the following:

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

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

"residential care amount" means:

(a) in relation to an entitled person in 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 an entitled person who is receiving, or received, residential care — an amount equivalent to the maximum daily amount of resident fees worked out under Division 58 of the Aged Care Act 1997.

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

"residential care (respite)" means residential care provided as respite.

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

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

“respite 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.

“Repatriation Commission” means the body corporate known as the Repatriation Commission and continued in existence under section 179 of the VEA.

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

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

"Rural Enhancement Scheme" means the scheme established by the Commission under subsection 84(1) of the VEA, 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.

“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.

“testing” means conducting a recognised medical test to identify malignant neoplasia (whether or not the person being tested has already been tested for, or diagnosed with, malignant neoplasia), but does not include conducting a test that replicates an existing community-wide government screening program.

“VEA” means the Veterans’ Entitlements Act 1986.

“VEA Repatriation Private Patient Principles” means the principles known as the Repatriation Private Patient Principles determined by the Commission under section 90A of the VEA.

“VEA Treatment Principles” means the document known as the “Treatment Principles” prepared by the Repatriation Commission under section 90 of the VEA.

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

“treatment” means treatment (within the meaning of subsection 80(1) of the Veterans’ Entitlements Act 1986) of malignant neoplasia, and includes testing.

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

"White Card" means

(a) 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 malignant neoplasia; or

(b) a written authorisation issued on behalf of the Commission under subparagraph 2.1.1(a)(ii).

1.4.2 In the 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 — ELIGIBILITY FOR TREATMENT OF MALIGNANT NEOPLASIA 2.1 Treatment for eligible persons in Australia
2.1.1 Subject to these Principles, the Commission may accept financial responsibility for the treatment in Australia of entitled persons who have been issued with:

(i) a White Card; or

(ii) a written authorisation issued on behalf of the Commission.

2.2 Treatment for entitled persons travelling overseas

2.2.1 Subject to these Principles, the Commission may accept financial responsibility for the treatment of malignant neoplasia suffered by an entitled person in the situation where the treatment is provided to the person outside Australia and the person is outside Australia temporarily.

Note: to be eligible for treatment a person must be an Australian resident.

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 malignant neoplasia while an entitled person is temporarily absent from Australia unless, prior to departure, an office of the Department has been notified of the person’s intention to travel.

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

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

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

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

(i) the amount charged the person; or

(ii) the amount of residential care subsidy (at classification level 1 for residential care or at classification level 3 for residential care (respite)) and the residential care amount (if any) that would have been accepted by the Commission in respect of the person if the person had received residential care or residential care (respite), as the case may be, at the classification level 1 or the classification level 3, respectively, for the same period in Australia;or

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

Note (2): 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 entitled person.

(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 an entitled person 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 outside Australia from Australia where a significant reason for that travel is to obtain treatment or rehabilitation appliances.

PART 3 — COMMISSION APPROVAL FOR TREATMENT OF MALIGNANT NEOPLASIA 3.1 Approval for treatment

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

Note: Schedule 3 provides that any approval given for treatment under the VEA Treatment Principles, as brought across by the Act, is deemed to have been given under, and for the purposes of, these Principles.

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 entered into by the Commission and, or, the Department, for the purposes of these Principles, the RPPPs or the VEA Repatriation Private Patient Principles.

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

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 outside Australia;

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

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

(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;

(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 LMO or other GP 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 RPPPs 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.

(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 optical product dispenser) to an entitled person where those optical products are dispensed in accordance with these Principles and an arrangement between the optometrist (or optical product dispenser) and the Commission or the Department;

Note: see principle 7.4.

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

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

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

(m) ambulance transport in an emergency or where that is the arrangement between ambulance service providers and the Commission entered into for the purposes of the VEA Treatment Principles;

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 for malignant neoplasia 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 of a condition associated with malignant neoplasia, for entitled persons, 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 outside Australia 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 eligible 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 eligible person has claimed or is entitled to claim from the Department of Human Services as a medicare benefit, a health insurance fund or another third party.

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

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

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

3.5 Financial responsibility

3.5.1 The extent of the financial liability accepted by the Commission for the provision of treatment to an entitled person by a health care provider is as follows:

(1) for fees charged by:

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

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

(b) a dentist (Local Dental Officer), including for dental services provided by a dental hygienist, dental therapist or oral health therapist on behalf of the dentist  the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dentists and Dental Specialists”, in force on the date in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the Notes for Allied Health Providers (Section 1 General Information and Section 2(c)(as section 2(c) affects dentists));

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

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

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

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

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

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

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

Chronic Pain Honorarium Fees;

Clinical Note Fees;

Compensation Consultation Fees;

Diagnostic Imaging Fee Schedule

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

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

Kilometre Allowance;

Local Medical Officers (LMOs) Fee Schedule;

Medication Review Fees;

Pathology Fee Schedule;

Ready Reckoner for LMOs

Relative Value Guide Fee Schedule;

Repatriation Medical Fee Schedule;

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

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

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

Chronic Pain Honorarium Fees;

Clinical Note Fees;

Compensation Consultation Fees;

Diagnostic Imaging Fee Schedule

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

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

Kilometre Allowance;

Medication Review Fees;

Pathology Fee Schedule;

Ready Reckoner for LMOs

Relative Value Guide Fee Schedule;

Repatriation Medical Fee Schedule;

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

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

Note: prior approval for a neuropsychologist’s treatment is required under the “Notes for Allied Mental Health Care Providers”.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3.5.2 The Commission will only accept financial responsibility for treatment:

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

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

(i) is in the form, if any, approved by the Commission for the purposes of paragraph 3.5.2 of the VEA Treatment Principles ('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 for the purposes of the VEA Treatment Principles.

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

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

, the Department of Human Services

3.5.2A Upon application in writing, by a claimant, to the Commission, the Commission may, in its discretion, by notice in writing served on the claimant, allow a longer period for lodging a claim than the period of 5 years referred to in subparagraph 3.5.2(c).

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

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

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

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

(a) services that have been paid for, wholly or partly, by the Department of Human Services, as a medicare benefit, or by a health insurance fund; or

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

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

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

PART 4 — MEDICAL PRACTITIONER SERVICES FOR MALIGNANT NEOPLASIA 4.1 Local Medical Officers / other General Practitioners

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 for malignant neoplasia.

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 but only if the medical treatment was for malignant neoplasia.

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 LMO 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 LMO 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 in respect of malignant neoplasia suffered by an entitled person where an LMO or other GP or specialist provides or arranges for treatment of:

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

(b) an entitled 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 LMO or other GP or specialist shall bill only:

(a) the Department; or

(b) the Commission; or

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 LMO 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 An LMO or other GP may refer an entitled person for:

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

(b) treatment of malignant neoplasia from a LMO 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

(d) other health-care services for malignant neoplasia 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 for malignant neoplasia, 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 LMO or other GP;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 LMO or other GP.

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

4.7 Referrals: prior approval

4.7.1 In all instances other than those described in paragraph 4.7.3 and the Repatriation Private Patient Principles (Australian Participants in British Nuclear Tests) 2006, prior approval is required for the referral of entitled persons to medical specialists.

4.7.2 Prior approval is required for 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.

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

4.8 Other matters

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

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

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

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

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

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

PART 5 — DENTAL TREATMENT IN RESPECT OF MALIGNANT NEOPLASIA 5.1 Providers of services

5.1.1 The Commission may accept financial responsibility for dental treatment in respect of a dental condition associated with malignant neoplasia if the treatment is provided to an entitled person by a dental prosthetist, dentist or dental specialist 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 in respect of a dental condition associated with malignant neoplasia.

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 (for malignant neoplasia) 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 (for malignant neoplasia) 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.

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

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 Eligibility

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

5.3.2 Persons who hold a White Card are entitled to dental treatment of a dental condition associated with malignant neoplasia and may 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;

(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 dental condition associated with malignant neoplasia for which the person is receiving treatment under principle 2.4.

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 for a dental condition associated with malignant neoplasia.

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 for a dental condition associated with malignant neoplasia, for entitled persons who hold a White 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 for a dental condition associated with malignant neoplasia of an entitled person who hold a White 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 Repatriation Pharmaceutical Benefits Scheme (Australian Participants in British Nuclear Tests) 2006

6.1.1 The Repatriation Pharmaceutical Benefits Scheme (Australian Participants in British Nuclear Tests) 2006 prepared under section 18 of the Act relates to the supply of Pharmaceutical Benefits to entitled persons by community pharmacists as defined in that Scheme.

6.2 Eligibility under the Repatriation Pharmaceutical Benefits Scheme (Australian Participants in British Nuclear Tests) 2006

6.2.1 A person is eligible to receive Pharmaceutical Benefits under the Repatriation Pharmaceutical Benefits Scheme (Australian Participants in British Nuclear Tests) 2006 if that person holds a White Card.

PART 7 — TREATMENT FROM ALLIED HEALTH PROVIDERS FOR CONDITIONS ASSOCIATED WITH MALIGNANT NEOPLASIA 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 this Part, 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.

7.1.2 Subject to these Principles and in addition to services provided under paragraph 5.1.3, the Commission may provide, arrange, or accept financial responsibility for, the following services in respect of treatment of a condition associated with malignant neoplasia:

(a) audiology

(aa) diabetes educator services;

(b) dietetics;

(d) community nursing;

(dd) exercise physiology;

(e) occupational therapy;

(f) optometry;

(g) orthoptics;

(h) osteopathic services;

(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.

7.1A Notes for Providers

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

Column A Column B

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

7.1B Disqualified Health Care Providers

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

7.2 Registration or enrolment of providers

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

Note: the occupational registration of community nursing providers is dealt with in the arrangements between the Commission and community nursing providers entered into for the purposes of the VEA Treatment Principles.

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

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.

7.3 Community nursing

7.3.3 The Commission will accept financial responsibility for community nursing services for an entitled person in respect of a condition associated with malignant neoplasia only if:

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

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

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

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

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

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

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

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

7.4 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 if the services are in respect of a condition associated with malignant neoplasia and provided 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 are for a condition associated with malignant neoplasia and 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

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, in respect of a condition associated with malignant neoplasia, 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 LMO 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, in respect of a condition associated with malignant neoplasia, 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 in respect of a condition associated with malignant neoplasia where a LMO or other GP or medical specialist refers an entitled person to a registered podiatrist (who has a provider number), for an episode of care.

7.6.2 Prior approval is required for podiatry treatment:

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

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

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

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

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

(g) providing an Electrodynographic Analysis and Report;

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

(i) delivering services valued at over $60 under the Miscellaneous Items listed in the Deed of Agreement between the Commission and the podiatrist entered into for the purposes of the VEA Treatment Principles.

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 the procedure is for a condition associated with malignant neoplasia and prior approval has been obtained.

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

(a) medical grade footwear;

(b) prescribed by a registered podiatrist, or a medical specialist who is a rehabilitation specialist, orthopaedic surgeon or rheumatologist; and

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

7.6A Diabetes Educator services

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

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

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

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

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

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

7.7 Chiropractic and osteopathic services

7.7.1 The Commission will accept financial responsibility for chiropractic or osteopathic services, in respect of a condition associated with malignant neoplasia, where a LMO 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 in relation to a condition associated with malignant neoplasia. No other treatment will be accepted.

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

7.7.5 The Commission will not accept financial responsibility for the provision of concurrent courses of physiotherapy and chiropractic services or physiotherapy and osteopathic services for the same condition to any entitled person.

7.8 Other services

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

(a) herbalist services;

(b) homeopathy;

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

(e) naturopathy.

PART 9 — TREATMENT OF ENTITLED PERSONS AT HOSPITALS AND OTHER INSTITUTIONS FOR MALIGNANT NEOPLASIA 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, for malignant neoplasia, 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 eligible 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 RPPPs, 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 RPPPs.

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, for the purposes of Part V VEA, 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, for malignant neoplasia, 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, for malignant neoplasia, 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 by the Commission with the appropriate State/Territory authority, or, in the absence of such arrangements, an amount in accordance with arrangements made by the Commission under Part V VEA with the appropriate State/Territory authority, for the purposes of the VEA; or

(b) for a contracted private hospital — the rate agreed between the Commission and the hospital or, in the absence of such an agreement, the rate agreed between the Commission and the hospital under Part V VEA for the purposes of the VEA;

(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, in the absence of such an agreement, the rate agreed between the Commission and the hospital under Part V VEA for the purposes of the VEA; or

(d) for a non-contracted hospital, when chosen by an entitled person in preference to a contracted private hospital — the rate agreed from time to time between the Commission and the hospital or, in the absence of such an agreement, the rate agreed between the Commission and the hospital under Part V VEA for the purposes of the VEA.

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

(a) hospital charges; or

(b) charges for any surgically implanted prostheses; or

in circumstances where the entitled person:

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

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

9.3 Nursing-home-type care for entitled persons with malignant neoplasia

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 for the condition of malignant neoplasia; 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 if the person is suffering from the effects of malignant neoplasia.

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.

9.3.3 Nothing in this Part is to be taken to permit payments to be made by the Commonwealth under both the Australian Participants in British Nuclear Tests (Treatment) Act 2006 and either the Veterans’ Entitlements Act 1986, 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, the Veterans’ Entitlements Act 1986, 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, as a consequence of treatment of the entitled person for a condition associated with malignant neoplasia, 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 FOR ENTITLED PERSONS SUFFERING FROM MALIGNANT NEOPLASIA
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 person who has a current valid White Card.

Note (1)‘residential care’ is defined in paragraph 1.4.1.

10.1.2 Subject to paragraph 10.1.3 and paragraph 10.1.5, a person referred to in paragraph 10.1.1 may be provided with residential care under the Aged Care Act 1997and the Principles if the person suffers from a condition associated with malignant neoplasia.

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

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

(b) accepted financial responsibility for that amount.

Note: The effect of paragraph 10.1.3 is to provide for payment to be made under the Australian Participants in British Nuclear Tests (Treatment) Act 2006 instead of the Aged Care Act 1997.

10.1.4 Paragraph 10.1.3 does not permit payments to be made by the Commonwealth under both the Australian Participants in British Nuclear Tests (Treatment) Act 2006 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 where the Principles so provide.

10.4 Payment of residential care amount for certain entitled persons

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

(a) has a dependant; and

(b) is receiving a high level of residential care because of a condition associated with malignant neoplasia.

Part B — residential care involving residential care (respite)

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

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

10.6 Residential care (respite) arrangements

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

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

Note (1): in Part B respite admission and residential care (respite) are interchangeable terms.

Note (2): the Residential Care Subsidy Principles (Principles) are made under subsection 96-1 (1) of the Aged Care Act 1997. Under Part 7 of the Principles the Secretary may increase the number of days a person may be provided with residential care as respite care by 21.

LIMITS OF FINANCIAL RESPONSIBILITY ACCEPTED BY THE REPATRIATION COMMISSION FOR RESPITE ADMISSION

category of patient

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

residential care (respite)

up to 28 days (inclusive) in a Financial year

residential care (respite)

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

entitled person

RCS + RCA

RCS

For the purposes of this table:

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

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

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

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

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

10.6.7 (1) For the purposes of paragraphs 10.6.1 to 10.6.3 (inclusive), a day means, in relation to residential care (respite) — a period of 24 hours.

Note: the "limit of days" for residential care (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.

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

Note (1): the effect of paragraph 10.6.8 is to provide for payment to be made under the Australian Participants in British Nuclear Tests (Treatment) Act 2006 instead of the Aged Care Act 1997.

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

10.6.9 Nothing in this Part is to be taken to permit payments to be made by the Commonwealth under both the Australian Participants in British Nuclear Tests (Treatment) Act 2006 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 or to a residential care facility not governed by the Aged Care Act 1997. The definition of residential care does not include hospital care.

10.8 The Commission may accept, in whole or in part, financial responsibility for respite provided to an entitled person who suffers from malignant neoplasia, for a maximum period of 28 days in a Financial year, where such respite is provided in an institution in respect of which a residential care subsidy is not payable if, in the opinion of the Commission, it is a cost-effective and appropriate alternative to residential care (respite) under paragraph 10.6.1.

PART 11 — THE PROVISION OF REHABILITATION APPLIANCES TO ENTITLED PERSONS SUFFERING FROM MALIGNANT NEOPLASIA 11.1 Rehabilitation Appliances Program

11.1.1 The Commission may accept financial responsibility for:

(a) surgical appliances; and

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

provided to an entitled person for use by that entitled person in relation to a condition associated with malignant neoplasia.

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

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

11.1.3 Appliances shall be provided:

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

(b) in an efficient manner of delivery; and

(d) in a cost effective manner; and

(e) on a timely basis.

11.1.4 An appliance that is provided should be:

(a) appropriate for its purpose;and

(b) safe for the particular entitled beneficiary; and

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

11.2 Supply of rehabilitation appliances

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

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

11.2A Prior Approval

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

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

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

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

11.3 Restrictions on the supply of certain items

11.3.1 Subject to this Part, the Commission will accept financial responsibility for the following appliances only where they are provided to entitled persons who have a medically assessed need for these items due to malignant neoplasia:

(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 person 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 accept financial responsibility for the provision of electronic communication equipment to an entitled person only where such equipment is provided to an entitled person who, due to suffering from malignant neoplasia, is:

(a) legally blind; or

(b) severely handicapped.

11.3.3 For the purposes of paragraph 11.3.2, a legally blind person means a person:

(a) whose legal blindness is caused by a condition associated with malignant neoplasia; and

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

11.3.4 For the purposes of paragraph 11.3.2, a severely handicapped person means a person:

(a) whose severe handicap is caused by a condition associated with malignant neoplasia; 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 person’s:

(i) communication skills; and

(ii) quality of life.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

rehabilitation appliance.

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

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

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

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

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

11.3.8 Subject to this Part, the Commission may 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 person who has a medically assessed need for these items because of a condition associated with malignant neoplasia.

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) if the visual aids have been provided for a condition associated with malignant neoplasia and 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

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 aid is for a condition associated with malignant neoplasia.

11.5.2 Where a person who has a condition associated with malignant neoplasia 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 malignant neoplasia or as a result of treatment of malignant neoplasia; or

(b) requires a wig as part of medical treatment for disfigurement due to a condition associated with malignant neoplasia.

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, for a condition of an entitled person that is associated with malignant neoplasia:

(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, for a condition of an entitled person that is associated with malignant neoplasia, the provision will be through:

(a) a stoma association; or

(b) the Pharmaceutical Benefits Scheme; or

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

11.7 Repair and replacement

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

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

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

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

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

11.7.4 The Commission may accept financial responsibility for the repair or replacement of a rehabilitation appliance while an entitled person is temporarily outside Australia.

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 accept financial responsibility for treatment aids as part of inpatient treatment for a condition associated with malignant neoplasia 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 accept financial responsibility for a treatment aid as part of inpatient or outpatient treatment where the treatment solely comprises the provision of the treatment aid.

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

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

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

11.9.1A For the purposes of paragraph 11.9.1:

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

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

11.9.1B Where the Commission approves financial assistance under paragraph 11.9.1 of the Principles before the commencement of the Treatment Principles (Australian Participants in British Nuclear Tests) 2006 (HomeFront - Frequency of Subsidy) Instrument 2009 (commencement date), and on the commencement date a period of 12 months had not expired from and including the date of that approval, the approval is taken to have been granted under the Principles as amended by the Treatment Principles (Australian Participants in British Nuclear Tests) 2006 (HomeFront - Frequency of Subsidy) Instrument 2009 and the period of 12 months commences on the date of the approval.

11.9.2 The Commission may give approval under paragraph 11.9.1 only if it has received a report from a home and safety assessor and the Commission is satisfied that the aid or appliance for which assistance is sought:

(a) is needed by the person for accident prevention or personal safety as part of the person’s preventive health care management in relation to a condition associated with malignant neoplasia; and

(b) is appropriate for its purpose; and

(d) is customarily used for domestic purposes and would be used for such purposes by the person; and

(e) would be provided or installed efficiently, cost effectively, and on a timely basis.

11.9.3 The arrangements entered into by the Commission with any person, for the purposes of paragraph 11.9.3 of the VEA Treatment Principles, whereby the person:

(a) is to provide the Commission with reports from home and safety assessors; or

(b) provide aids and appliances for accident prevention and personal safety;

apply for the purposes of this Part as if entered into by the Commission under this Part.

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 referred to in paragraph 11.9.3.

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

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

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

11.9.7 The Commonwealth will not be financially responsible for the maintenance or repair of any aid or appliance for which the Commission has approved financial assistance under this Principle.

11.9.8 Neither the Commonwealth nor the Commission will 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 MATTERS RELATING TO TREATMENT OF MALIGNANT NEOPLASIA 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 for transport for a condition associated with malignant neoplasia.

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

(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 entered into for the purposes of paragraph 12.1.5 of the VEA Treatment Principles.

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 eligible 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 Subject to the Act, 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

(d) any other cause.

Note: Division 3 of Part 5 of the Act applies to payments induced by false statements etc

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 48 of the Act, by offsetting moneys for any excess amounts against any later claims for payment by that person or body; or

Note: Section 48 provides, in effect, that where amounts have been overpaid, the Commission may, if the person agrees, offset moneys owed against later claims.

(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.

Legislation content

12.6 Recovery of moneys

PART 1 — INTRODUCTION

1.2 Application of Repatriation Private Patient Principles (Australian Participants in British Nuclear Tests) 2006

1.4 Interpretation

2.2 Treatment for entitled persons travelling overseas

PART 3 — COMMISSION APPROVAL FOR TREATMENT OF MALIGNANT NEOPLASIA 3.1 Approval for treatment

3.2 Circumstances in which prior approval is required

3.3 Circumstances in which prior approval is not required

3.4 Other retrospective approval

3.5 Financial responsibility

4.2 Providers of services

4.3 Financial responsibility

4.5 Referrals by medical specialists

4.7 Referrals: prior approval

4.8 Other matters

PART 5 — DENTAL TREATMENT IN RESPECT OF MALIGNANT NEOPLASIA 5.1 Providers of services

5.2 Financial responsibility

5.3 Eligibility

5.4 Emergency dental treatment

5.6 General anaesthesia

5.7 Prescribing of pharmaceutical benefits by dentists

5.8 Other dental services

PART 6 — PHARMACEUTICAL BENEFITS

PART 7 — TREATMENT FROM ALLIED HEALTH PROVIDERS FOR CONDITIONS ASSOCIATED WITH MALIGNANT NEOPLASIA 7.1 Prior approval and financial responsibility for health services

7.2 Registration or enrolment of providers

7.3 Community nursing

7.4 Optometrical services

7.5 Physiotherapy

7.6 Podiatry

7.7 Chiropractic and osteopathic services

7.8 Other services

PART 9 — TREATMENT OF ENTITLED PERSONS AT HOSPITALS AND OTHER INSTITUTIONS FOR MALIGNANT NEOPLASIA 9.1 Admission to a hospital or institution

9.2 Financial Responsibility For Treatment In Hospital

9.3 Nursing-home-type care for entitled persons with malignant neoplasia

9.5 Convalescent care

9.6 Other matters

10.1 Residential care arrangements

10.4 Payment of residential care amount for certain entitled persons

PART 11 — THE PROVISION OF REHABILITATION APPLIANCES TO ENTITLED PERSONS SUFFERING FROM MALIGNANT NEOPLASIA 11.1 Rehabilitation Appliances Program

11.2 Supply of rehabilitation appliances

11.3 Restrictions on the supply of certain items

11.4 Visual aids

11.5 Hearing aids

11.6 Other rehabilitation appliances

11.7 Repair and replacement

11.8 Treatment aids from hospitals

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

PART 12 — OTHER MATTERS RELATING TO TREATMENT OF MALIGNANT NEOPLASIA 12.1 Ambulance transport

12.2 Treatment under Medicare Program

12.4 Prejudicial or unsafe acts or omissions by patients

12.6 Recovery of moneys

Interactions

Authorises

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