PART 9 — TREATMENT OF ENTITLED PERSONS AT HOSPITALS AND INSTITUTIONS
9.1 Admission to a hospital or institution
9.1.1 Subject to these Principles, the Commission will accept financial responsibility for the provision of treatment to entitled persons at a hospital or an institution.
9.1.2 The Commission will not approve, or accept financial responsibility for, admission to a hospital or an institution if:
(b) the person could have been provided with suitable outpatient treatment; or
(c) the person could have been suitably cared for at home, with or without supporting community health care services, unless the admission would provide respite for a carer of an entitled person.
9.1.3 Notwithstanding other provisions of these Principles, the Commission will accept financial responsibility for the emergency admission to the nearest hospital of an entitled person for treatment if an office of the Department is notified on the first working day after the admission, or as soon thereafter as is reasonably practicable if that admission is to a private hospital requiring prior approval as set out in Part 3 of these Principles.
9.1.4 Where hospital treatment of an entitled person has been arranged under these Principles, and the person’s partner is an inpatient at another hospital within reasonable proximity, the Commission may arrange the admission or transfer of the person to the hospital at which the person’s partner is an inpatient.
9.1.5 If such arrangements are made under paragraph 9.1.4, the Commission will accept financial responsibility for the hospital treatment of the entitled person.
9.1.6 The Commission will accept financial responsibility for the admission of an entitled person to a Tier 2 or Tier 3 hospital, as set out in Principle 2 of the MPPPs, only if prior approval for the admission is obtained.
9.1.7 When giving consideration of prior approval under paragraph 9.1.6, the Commission will have regard to the matters set out in paragraph 3.2.2 and in Principle 2 of the MPPPs.
9.1.8 Subject to this Part, the Commission will accept financial responsibility for inpatient treatment of an entitled person in a country or a Territory public hospital or in a private hospital with which arrangements have been previously agreed with the Commission and according to the preferences and requirements set out in Part 3 of these Principles and in Principle 2 of the RPPPs.
9.1.9 The Commission’s approval is required before it will accept financial responsibility for the admission to hospital, or for hospital treatment, of entitled persons in all other circumstances.
9.1.10 Where prior approval is required, the Commission will not accept financial responsibility for any additional charges where an admission for treatment is arranged according to these Principles and then non‑Medicare Benefits Schedule surgery or cosmetic surgery is performed subsequently without the Commission's approval.
9.2 Financial Responsibility For Treatment In Hospital
9.2.1 Subject to paragraph 9.2.5, the Commission will accept financial responsibility for any usual and reasonable hospital treatment that takes place at the hospital for persons admitted in accordance with these Principles.
9.2.2 The Commission may accept financial responsibility for any usual and reasonable treatment that takes place outside the hospital if it is prescribed as a necessary part of inpatient treatment.
9.2.4 Subject to paragraph 9.2.5, the Commission will accept financial responsibility for hospital charges on the basis of:
(a) for a public hospital — an amount in accordance with arrangements made with the appropriate State/Territory authority; or
(b) for a contracted private hospital — the rate agreed between the Commission and the hospital; or
(c) for a non‑contracted private hospital, when neither a public nor a contracted private hospital can provide the treatment required — the rate agreed from time to time between the Commission and the hospital; or
(d) for a non‑contracted hospital, when chosen by an entitled person in preference to a contracted private hospital — a rate to be determined by the Commission.
9.2.5 The Commission will not accept financial responsibility for the whole, or that portion, of:
(a) hospital charges; or
(b) charges for any surgically implanted prostheses; or
(c) charges paid by health fund benefits,
in circumstances where the entitled person:
(d) is insured by private health insurance for hospital charges or surgically implanted prostheses; and
(e) agrees to assign to the hospital or other institution the benefits available from private health insurance in respect of all or part of the hospital charges or surgically implanted prostheses.
9.3 Nursing‑home‑type care
9.3.1 Where:
(a) an entitled person remains an inpatient in excess of 35 consecutive days and there is no acute care certificate under section 3B of the Health Insurance Act 1973 in force stating reasons approved by the Commission for the continuing need for acute care; or
(b) the medical practitioner responsible for treating the entitled person agrees at any time after admission that the entitled person no longer requires acute care;
the person will be regarded as receiving nursing‑home‑type care.
9.3.2 If an entitled person:
(a) is eligible for care from a registered provider for which the registered provider is eligible for a residential care subsidy; 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 daily care fee, unless:
(c) the Commission has granted an exemption under paragraph 10.2.1;
in which case the Commission will accept financial responsibility for the full amount of the hospital charge.
9.3.3 Nothing in this Part is to be taken to permit payments to be made by the Commonwealth under both the Act and either the Aged Care Act 2024 or the National Health Act 1953 in respect of the same amount for which the Commonwealth has become liable in respect of nursing‑home‑type care under these Principles or the Aged Care Act 2024 or the National Health Act 1953.
9.5 Convalescent care
convalescent care in institutions other than hospitals
9.5.1 Subject to prior approval and subject to paragraph 9.2.5 (health insurance etc), the Commission will accept financial responsibility for the costs of convalescent care for an entitled person at an institution other than a private hospital or public hospital for a maximum of 21 days during any financial year.
convalescent care in institutions that are private or public hospitals
9.5.2 Subject to paragraph 9.2.5 (health insurance etc), the Commission may accept financial responsibility for the costs of convalescent care for an entitled person at a private hospital or public hospital.
Note (1) prior approval is not a requirement in these circumstances.
Note (2) there is no express time limit in these circumstances but the Commission has a discretion to accept financial responsibility. It could exercise its discretion not to accept financial responsibility if it considered the length of convalescent care to be excessive.
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.