I, Michael Ronaldson, Minister for Veterans’ Affairs, approve this instrument under subsection 286(3) of the Military Rehabilitation and Compensation Act 2004. Dated this 18th day of August 2015Michael RonaldsonMICHAEL RONALDSON
The Military Rehabilitation and Compensation Commission makes this instrument under under paragraph 286(1)(b) of the Military Rehabilitation and Compensation Act 2004.Dated this 6th day of August 2015The Seal of the )Military Rehabilitation and Compensation Commission) SEALwas affixed hereto in the )presence of: ) Simon Lewis Craig Orme...................................................................................................................................................................SIMON LEWIS CRAIG ORME AM CSC CHAIR DEPUTY PRESIDENT Jennifer Taylor Air Vice-Marshal Tony Needham………………………………….............................................................................................................................................…… Ms JENNIFER TAYLOR Air Vice-Marshal tony Needham AMMEMBER MEMBER
4.3 Criteria for Tier 2 or Tier 3 hospital admission and treatment
4.4 Admission to Tier 3 hospital of choice
4.5 Commonwealth liability if Tier 3 admission by choice
5. Treatment Monitoring
5.1 Consultative Forum
1. Preliminary
1.1 Principles
1.1.1 These Principles are the MRCA Private Patient Principles 2004.
1.1.2 These Principles commence when the Repatriation Private Patient Principles (Instrument 2015 No. R33) commences.
Note: the Repatriation Private Patient Principles commence on the day after registration.
1.2 Defined terms
For the purposes of these Principles, unless a contrary intention appears:
Act means the Military Rehabilitation and Compensation Act 2004 in force from time to time.
admission means admission for treatment as an in-patient or day-patient upon the referral of a medical specialist or a Local Medical Officer.
Commission means the Military Rehabilitation and Compensation Commission established under section 361 of the Act.
consultative forum means the forum in each State established by the Department of Veterans’ Affairs for the purpose of, among other functions, monitoring the treatment of entitled persons and consisting of representatives of the Military Rehabilitation and Compensation Commission, the Repatriation Commission and the ex-service community.
contracted private hospital means a private hospital in respect of which the Commission has entered into arrangements under section 285 of the Act for the treatment of entitled persons.
Department means the Australian Government Department of Veterans’ Affairs.
emergency means a situation in which a person requires immediate treatment because of a serious threat to the person’s life or health.
entitled person means a person entitled to treatment under Part 3 of Chapter 6 of the Act
former Repatriation Hospital means a hospital or other institution that was formerly operated by the Repatriation Commission under paragraph 89(1)(a) of the Veterans’ Entitlements Act 1986.
Note: see the Repatriation Institutions (Transfer) Act 1992
Local Medical Officer means a 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 the MRCA Treatment Principles and in the “Notes for Local Medical Officers”; and
(b) has been given a provider number by Medicare, in respect of being a medical practitioner, that has not been suspended or revoked.
medical practitioner means a person registered or licensed as a medical practitioner under a law of a State or Territory that provides for the registration or licensing of medical practitioners but does not include a person so registered or licensed:
(a) whose registration, or licence to practise, as a medical practitioner 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 medical practitioner in that State or Territory.
medical specialist means a medical practitioner who is recognised as a consultant physician or specialist in the appropriate specialty for the purposes of the Health Insurance Act 1973.
Medicare means the Chief Executive Medicare under Part IIA of the Human Services (Medicare) Act 1973.
MRCA Treatment Principles means the determination by the Commission under paragraph 286(1)(a) of the Act that sets out the circumstances in which, and conditions subject to which, treatment may be provided to entitled persons.
Notes for Local Medical Officers has the same meaning it has in the MRCA Treatment Principles.
Principles means the current MRCA Private Patient Principles determined by the Commission under paragraph 286(1)(b) of the Act that sets out, among other things, the circumstances in which treatment may be provided to entitled persons as private patients.
prior approval means:
(a) in relation to treatment—approval by the Commission for treatment before the treatment was given or commenced to be given; and
(b) in relation to admission to a hospital—approval by the Commission for admission to that hospital before the person is admitted.
private hospital means premises that have been declared to be:
(a) a private hospital for the purposes of the Health Insurance Act 1973; or
(b) a day hospital facility for the purposes of the National Health Act 1953.
private patient has the meaning given by subsection 286(7) of the Act.
private health insurer has the meaning it has in the Private Health Insurance Act 2007.
public hospital means a hospital operated by a State or Territory or by the Commonwealth.
Repatriation Commission means the body continued in existence by section 179 of the Veterans’ Entitlements Act 1986.
Repatriation Private Patient Principles means the principles determined by the Repatriation Commission under section 90A of the Veterans’ Entitlements Act 1986.
veteran partnering private hospital means a contracted private hospital that is described as a “veteran partnering private hospital” in its arrangement with the Commission.
Note: other Tier 1 status hospitals which have similar partnering arrangements are public hospitals and former Repatriation Hospitals.
1.3 Private patient status
An entitled person is to receive hospital care as a private patient — which entitles the person to:
(a) the patient’s choice of doctor, subject to the doctor having practising rights at the relevant hospital; and
(b) shared accommodation; or
(c) if medically necessary, private accommodation; or
(d) private accommodation, if available, where the person’s private health insurer will pay the difference between the cost of shared accommodation and the cost of private accommodation for the person; or
(e) on and after 1 July 2016, private accommodation, if available, in a contracted private hospital.
2. Order of preference for admission to hospital
2.1 Order of preference
Preference for admission is to be in accordance with the following table:
Level
Preference
Hospital
Tier 1
first
former Repatriation Hospital, public hospital, or veteran partnering private hospital
Tier 2<br>(special authorisation)
second
The Contracted private hospital is not required to seek prior approval for a referral for services specified in the contract, chargeable to DVA, from a Tier 1 hospital. The Contracted private hospital must seek prior approval for all other admissions.
Tier 2
second
Contracted private hospital
Tier 3
third
Non-Contracted private hospital
2.2 Objective
The main objective of these Principles is to provide an entitled person with access to the nearest suitable hospital.
3. Prior approval not required
3.1 Medical specialist treatment
A medical specialist or Local Medical Officer may, without prior approval, refer an entitled person to a medical specialist for treatment as a private patient (whether that medical specialist works at a hospital or at consulting room facilities) only if the fee to be charged by that medical specialist for that treatment is no greater than the fee the medical specialist could charge for the treatment pursuant to the MRCA Treatment Principles.
3.2 Non-emergency Tier 1 hospital treatment
An entitled person may be admitted to a Tier 1 hospital for non-emergency treatment without prior approval.
3.3. Non-emergency Tier 2 hospital treatment
An entitled person may be admitted to a Tier 2 hospital for non-emergency treatment without prior approval only in those circumstances where the arrangements relating to that hospital specifically exclude the need for prior approval.
3.4. Emergency hospital treatment
An entitled person may be treated at, and admitted through, the accident and emergency centre of a Tier 1, 2, or 3 hospital for emergency treatment without prior approval.
3.5 Notification of admission
If an entitled person is admitted to a Tier 2 or Tier 3 hospital under paragraph 3.4, the hospital must notify the Department of that admission the next working day in the State or Territory in which the admission occurred, or as soon as practicable afterwards.
4. Prior approval required
4.1 Tier 2 hospital admission and treatment
Subject to Principle 3, an entitled person may be admitted to, and have continuing treatment in, a Tier 2 hospital only if a suitable Tier 1 hospital is unavailable and prior approval has been obtained for the admission.
4.2 Tier 3 hospital admission and treatment
Subject to paragraph 3.4, an entitled person may be admitted to, and have continuing treatment in, a Tier 3 hospital only if no suitable Tier 1 or Tier 2 hospital is available and prior approval has been obtained.
4.3 Criteria for Tier 2 or Tier 3 hospital admission and treatment
In deciding whether prior approval will be given under paragraph 4.1 or 4.2 for:
(a) admission to; or
(b) continued, non-emergency, treatment in;
a Tier 2 or Tier 3 hospital, the Commission must consider where the person’s needs can most appropriately be met within a reasonable time, having regard to:
(c) advice from the person’s treating medical practitioner concerning:
(i) the injury or disease being treated; and
(ii) the clinical need for the proposed treatment; and
(iii) the degree of pain or discomfort; and
(iv) the effect on the person’s quality of life
(d) in light of the severity of the entitled person’s clinical condition:
(i) the waiting time, if any, at that hospital compared with waiting times, if any, at relevant Tier 1 or Tier 2 hospitals, as the case may be; and
(ii) the distance that the entitled person would have to travel; and
(e) reasonable control over Commonwealth expenditure; and
(f) the extent of a clinical need for continuity of care by a particular medical practitioner; and
(g) any other relevant requirement in these Principles or in the Act.
4.4 Admission to Tier 3 hospital of choice
If prior approval has been given for an entitled person to be admitted to a Tier 2 hospital for the purpose of particular treatment, or an entitled person has been admitted for treatment to a Tier 2 hospital in accordance with paragraph 3.3, the person may elect to be admitted to a Tier 3 hospital of his or her choice for that treatment.
4.5 Commonwealth liability if Tier 3 admission by choice
If an entitled person, in accordance with paragraph 4.4, elects to be admitted to a Tier 3 hospital, the Commonwealth will be liable only for:
(a) accommodation costs; and
(b) pharmaceutical fees; and
(c) theatre fees; and
(d) certain incidental expenses;
provided such costs, fees or expenses are, in the Commission’s opinion, reasonable.
5. Treatment Monitoring
5.1 Consultative Forum
5.1.1 A consultative forum is given the function of monitoring these Principles, especially in respect of access to, and quality of, the care, welfare and treatment provided to entitled persons. In particular, the consultative forum has the role of receiving and considering comments and concerns, and providing information relating to these issues to the ex-service community.