PART 9 — TREATMENT OF ENTITLED PERSONS AT HOSPITALS AND INSTITUTIONS
9.1 Admission to a hospital or institution
9.1.1 Subject to these Principles, the Commission will accept financial responsibility for the provision of treatment to entitled persons at a hospital or an institution.
9.1.2 The Commission will not approve, or accept financial responsibility for, admission to a hospital or an institution if:
(b) the person could have been provided with suitable outpatient treatment; or
(c) the person could have been suitably cared for at home, with or without supporting community health care services, unless the admission would provide respite for a carer of an entitled person.
9.1.3 Notwithstanding other provisions of these Principles, the Commission will accept financial responsibility for the emergency admission to the nearest hospital of an entitled person for treatment if an office of the Department is notified on the first working day after the admission, or as soon thereafter as is reasonably practicable if that admission is to a private hospital requiring prior approval as set out in Part 3 of these Principles.
9.1.4 Where hospital treatment of an entitled person has been arranged under these Principles, and the person’s partner is an inpatient at another hospital within reasonable proximity, the Commission may arrange the admission or transfer of the person to the hospital at which the person’s partner is an inpatient.
9.1.5 If such arrangements are made under paragraph 9.1.4, the Commission will accept financial responsibility for the hospital treatment of the entitled person.
9.1.6 The Commission will accept financial responsibility for the admission of an entitled person to a Tier 2 or Tier 3 hospital, as set out in Principle 2 of the MPPPs, only if prior approval for the admission is obtained.
9.1.7 When giving consideration of prior approval under paragraph 9.1.6, the Commission will have regard to the matters set out in paragraph 3.2.2 and in Principle 2 of the MPPPs.
9.1.8 Subject to this Part, the Commission will accept financial responsibility for inpatient treatment of an entitled person in a country or a Territory public hospital or in a private hospital with which arrangements have been previously agreed with the Commission and according to the preferences and requirements set out in Part 3 of these Principles and in Principle 2 of the RPPPs.
9.1.9 The Commission’s approval is required before it will accept financial responsibility for the admission to hospital, or for hospital treatment, of entitled persons in all other circumstances.
9.1.10 Where prior approval is required, the Commission will not accept financial responsibility for any additional charges where an admission for treatment is arranged according to these Principles and then non-Medicare Benefits Schedule surgery or cosmetic surgery is performed subsequently without the Commission's approval.
9.2 Financial Responsibility For Treatment In Hospital
9.2.1 Subject to paragraph 9.2.5, the Commission will accept financial responsibility for any usual and reasonable hospital treatment that takes place at the hospital for persons admitted in accordance with these Principles.
9.2.2 The Commission may accept financial responsibility for any usual and reasonable treatment that takes place outside the hospital if it is prescribed as a necessary part of inpatient treatment.
9.2.4 Subject to paragraph 9.2.5, the Commission will accept financial responsibility for hospital charges on the basis of:
(a) for a public hospital — an amount in accordance with arrangements made with the appropriate State/Territory authority; or
(b) for a contracted private hospital — the rate agreed between the Commission and the hospital; or
(c) for a non-contracted private hospital, when neither a public nor a contracted private hospital can provide the treatment required — the rate agreed from time to time between the Commission and the hospital; or
(d) for a non-contracted hospital, when chosen by an entitled person in preference to a contracted private hospital — a rate to be determined by the Commission.
9.2.5 The Commission will not accept financial responsibility for the whole, or that portion, of:
(a) hospital charges; or
(b) charges for any surgically implanted prostheses; or
(c) charges paid by health fund benefits,
in circumstances where the entitled person:
(d) is insured by private health insurance for hospital charges or surgically implanted prostheses; and
(e) agrees to assign to the hospital or other institution the benefits available from private health insurance in respect of all or part of the hospital charges or surgically implanted prostheses.
9.3 Nursing-home-type care
9.3.1 Where:
(a) an entitled person remains an inpatient in excess of 35 consecutive days and there is no acute care certificate under section 3B of the Health Insurance Act 1973 in force stating reasons approved by the Commission for the continuing need for acute care; or
(b) the medical practitioner responsible for treating the entitled person agrees at any time after admission that the entitled person no longer requires acute care;
the person will be regarded as receiving nursing-home-type care.
9.3.2 If an entitled person:
(a) is eligible for a residential care subsidy under the Aged Care Act 1997; and
(b) is receiving nursing-home-type care as defined in paragraph
9.3.1;
the Commission will accept financial responsibility for the standard hospital fee for nursing-home-type patients under the National Health Act 1973, or other agreed fee, less the residential care amount, unless:
(c) the Commission has granted an exemption under paragraph 10.2.1;
in which case the Commission will accept financial responsibility for the full amount of the hospital charge.
9.3.3 Nothing in this Part is to be taken to permit payments to be made by the Commonwealth under both the Act and either the Aged Care Act 1997 or the National Health Act 1953 in respect of the same amount for which the Commonwealth has become liable in respect of nursing-home-type care under these Principles or the Aged Care Act 1997 or the National Health Act 1953.
9.5 Convalescent care
9.5.1 Subject to prior approval and subject to paragraph 9.2.5, the Commission will accept financial responsibility for the costs of convalescent care for an entitled person at an institution for a maximum of 21 days during any financial year.
9.6 Other matters
9.6.1 The Commission may withdraw its approval, at any time, for an entitled person’s continued inpatient treatment in a hospital or other institution.
PART 10 — RESIDENTIAL CARE, CARE AT HOME PACKAGES AND TRANSITION CARE CO-PAYMENT
Part A — residential care not involving residential care (respite)
Note: this heading is intended to be an aid in interpretation.
10.1 Residential care arrangements
10.1.1 Residential care may be provided in accordance with this Part to:
(a) a person who has a current valid Gold Card; or
(b) a person who has a current valid White Card.
Note :‘residential care’ is defined in paragraph 1.4.1.
10.1.2 Subject to paragraph 10.1.3 and paragraph 10.1.5, a person referred to in paragraph 10.1.1 may be provided with residential care under the Aged Care Act 1997 and the Principles.
10.1.3 Upon the Commonwealth becoming liable to pay an amount under the Aged Care Act 1997 in respect of residential care for a person referred to in paragraph 10.1.1, the Commission is taken to have:
(a) arranged for the provision of that residential care in accordance with this Part; and
(b) accepted financial responsibility for that amount.
Note: The effect of paragraph 10.1.3 is to provide for payment to be made under the Act instead of the Aged Care Act 1997. Section 96-10 of the Aged Care Act 1997 provides that subsidies payable under Chapter 3 of the Aged Care Act 1997 in respect of treatment under Division 4 of Part 3 of Chapter 6 of the Act are not payable as an automatic appropriation out of the Consolidated Revenue Fund under the Aged Care Act 1997 but are payable out of that Fund in accordance with the relevant appropriation provisions relating to the arrangement of treatment by the Commission under the Act.
10.1.4 Paragraph 10.1.3 does not permit payments to be made by the Commonwealth under both the Act and the Aged Care Act 1997 in respect of the same amount for which the Commonwealth has become liable.
10.1.5 Despite paragraph 10.1.3, where residential care is provided to an entitled person under the Aged Care Act 1997 and the Commonwealth is not liable to pay an amount under that Act in respect of an amount incurred by the entitled person in relation to that care, the Commission may accept financial liability for any such amount incurred by the entitled person where the Principles so provide.
Note:under the Aged Care Act 1997 the Commonwealth is not necessarily liable to pay resident fees such as the residential care amount. Liability to pay that amount may be accepted by the Commission under the Principles.
10.2 Payment of residential care amount for certain entitled members with dependants
10.2.1 The Commission may, in exceptional circumstances, accept financial responsibility for the residential care amount for an entitled member who:
(a) has a dependant; and
(b) is receiving a high level of residential care because of a service injury or a service disease or both.
Part B — residential care involving residential care (respite)
Note (1): this heading is intended to be an aid in interpretation.
Note (2): in Part B respite admission and residential care (respite) are interchangeable terms.
10.3 Residential care (respite) arrangements
10.3.1 residential care (respite) may be provided to an entitled person in accordance with this Part.
Note: residential care (respite) includes residential care (28 day respite) under the MRCA Home Care Program.
10.3.2 The Commission may, in accordance with the following Table and subject to this Part, accept financial liability for the provision of residential care (respite) to an entitled person for a period not exceeding 63 days in a Financial year or not exceeding such further period in a Financial year for which residential care provided as respite to the person is permitted under the Residential Care Subsidy Principles.
Note (1): in calculating the maximum period of residential care (respite) available to an entitled person for which the Commission may meet certain costs, periods of residential care (28 day respite) (where the Commission paid the residential care amount) and in-home respite will be counted.
Note (2) in Part B respite admission and residential care (respite) are interchangeable terms and residential care (respite) includes residential care (28 day) respite.
Note (4): the Residential Care Subsidy Principles (Principles) are made under subsection 96-1 (1) of the Aged Care Act 1997. Under Part 7 of the Principles the Secretary may increase the number of days a person may be provided with residential care as respite care by 21.
LIMITS OF FINANCIAL RESPONSIBILITY ACCEPTED BY THE COMMISSION FOR RESPITE ADMISSION
category of patient
type of care; max.period of care permitted; type of care costs accepted
type of care; max.period of care permitted; type of care costs accepted
residential care (28 day respite)up to 28 days (inclusive) in a Financial year
residential care (respite) other than residential care (28 day respite)upon an entitled person exhausting 28 days of residential care (28 day respite) in a Financial year — between and including 29 to 63 days* in that Financial year
entitled person
RCS + RCA
RCS
For the purposes of this table:
‘RCA’ means the Commission will accept financial responsibility for the residential care amount.
‘RCS’ means the Commission will accept financial responsibility for the residential care subsidy.
‘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.
10.3.4 Where the Commission could accept financial liability for a residential care amount otherwise payable by an entitled person in respect of a day in residential care, but does not accept liability because the entitled person chooses to accept that liability , then that day:
(a) is not to be taken into account in calculating if the person has been a respite admission for 63 days or such further period permitted under the Residential Care Subsidy Principles; and
(b) is not to be taken into account in calculating if the person has been provided with in-home respite for a period exceeding 28 days in a Financial year.
10.3.5 Where the Commission accepts financial liability for a residential care amount otherwise payable by an entitled person in respect of a day in residential care in a Financial year, then that day is to be taken into account in calculating if the person would receive in-home respite for more than 28 days in that Financial year.
10.3.6 Where the Commission accepts financial liability for the provision of in-home respite to an entitled person on a day, then that day is to be taken into account in calculating if the person has been a respite admission for 63 days (or such further period permitted under the Residential Care Subsidy Principles).
10.3.7 Where the Commission accepts financial liability for the provision of emergency short term home relief on a day, then that day is not to be taken into account in calculating if the person has been a respite admission for 63 days (or such further period permitted under the Residential Care Subsidy Principles ) or if the person has received in-home respite for more than 28 days.
10.3.8 (1) For the purposes of paragraphs 10.3.1 to 10.3.7 (inclusive) and subject to paragraph (2), a day means:
(a) in relation to residential care (respite) — a period of 24 hours;or
(b) in relation to in-home respite — a period of 7 hours.
(2) For the purpose of determining if the limit of days for residential care (respite) has been reached by reference to the number of days an entitled person spent in in-home respite, a day of 7 hours in in-home respite is taken to have been a day of 24 hours, and for the purpose of determining if the limit of days for in-home respite has been reached by reference to the number of days an entitled person spent in residential care (respite), a day of 24 hours in residential care (respite), is taken to have been a day of 7 hours.
Note: the "limit of days" for residential care (respite) or for in-home respite means the maximum number of days for which the Commission may accept financial liability for - in the case of residential care (respite), the residential care subsidy or the residential care subsidy and the residential care amount, or for - in the case of in-home respite, the cost of respite
10.3.9 Upon the Commonwealth or an entitled person becoming liable to pay an amount under the Aged Care Act 1997 in respect of residential care (respite) provided to that person and the Commission assuming financial responsibility for that amount, the Commission is taken to have arranged for the provision of that residential care (respite) to that entitled person in accordance with this Part.
Note (1): the effect of paragraph 10.6.8 is to provide for payment to be made under the Act instead of the Aged Care Act 1997. Section 96-10 of the Aged Care Act 1997 provides that subsidies payable under Chapter 3 of the Aged Care Act 1997 in respect of treatment under Division 4 of Part 3 of Chapter 6 of the Act are not payable as an automatic appropriation out of the Consolidated Revenue Fund under the Aged Care Act 1997 but are payable out of that Fund in accordance with the relevant appropriation provisions relating to the arrangement of treatment by the Commission under the Act.
Note (2): the amount an entitled person could be liable to pay for residential care (respite) is the residential care amount, being a resident's contribution to his or her care.
10.3.10 Nothing in this Part is to be taken to permit payments to be made by the Commonwealth under both the Act and the Aged Care Act 1997 in respect of the same amount for which the Commonwealth has become liable in respect of residential care (respite) under these Principles or the Aged Care Act 1997.
Part C — respite admissions not involving residential care (respite)
Note (1): this heading is intended to be an aid in interpretation.
Note (2): an example of a respite admission not involving residential care (respite) would be an admission to a hospital. The definition of residential care does not include hospital care.
10.4 The Commission may accept, in whole or in part, financial responsibility for respite for a maximum period of 28 days in a Financial year in an institution in respect of which a residential care subsidy is not payable if, in the opinion of the Commission, it is a cost-effective and appropriate alternative to residential care (respite) under paragraph 10.3.1 and to Respite Care under the MRCA Home Care Program.
Part D - CARE AT HOME PACKAGES
10.5 The Commission may accept financial responsibility for a Community Aged Care Package or Extended Aged Care at Home Package for a former prisoner of war, or an entitled member awarded the Victoria Cross for Australia (VC recipient), who is receiving (or who has received) such a care package.
10.6 Financial responsibility is limited to responsibility for the amount (co-payment) the former prisoner of war or VC recipient paid, or is to pay, pursuant to an agreement with the provider of the care package — to the extent the co-payment does not exceed any limit under:
(a) the Aged Care Act 1997;
(b) instruments under the Aged Care Act 1997; or
(c) any agreement between the provider of the care and the Secretary of the Department that administers the Aged Care Act 1997;
and financial responsibility does not include responsibility for the cost of the care package that would otherwise be subsidised under the Aged Care Act 1997.
10.7 In deciding whether to accept financial responsibility for a Community Aged Care Package or Extended Aged Care at Home Package provided to a former prisoner of war or VC recipient the Commission should take into account:
(a) whether the care was provided in accordance with the relevant provisions of the Aged Care Act 1997 and the relevant instruments thereunder;
(b) whether the care complies with the requirements of any agreement between the provider of the care and the Secretary of the Department that administers the Aged Care Act 1997; and
(c) whether the care essentially duplicates treatment the former prisoner of war or VC recipient is receiving under other provisions of the Principles (double-dipping).
10.8 Billing
10.8.1 The provider of a Community Aged Care Package or Extended Aged Care at Home Package should bill Medicare Australia rather than the former prisoner of war or VC recipient (client) but if the client is billed, the Commission may, subject to paragraph 10.6, accept financial liability for the amount.
Part E – TRANSITION CARE CO-PAYMENT
10.9 Financial Responsibility for Co-Payment
10.9.1 Subject to 10.9.2 the Commission may accept financial responsibility for transition care (care) provided by an approved provider to:
(a) an entitled member who is former prisoner of war (POW); or
(b) an entitled member awarded the Victoria Cross for Australia (VC recipient);
on condition that the care is provided on a day in respect of which flexible care subsidy is payable for the care under the Flexible Care Subsidy Principles 1997.
Note: as at December 2010 the maximum number of days for which flexible care subsidy was payable for transition care was 126 days.
10.9.2 For 10.9.1, financial responsibility is limited to responsibility for the amount (co-payment) the POW or VC recipient paid, or is to pay, to an approved provider — to the extent:
(a) the co-payment does not exceed the amount the approved provider is permitted to charge the POW or VC recipient under section 56-3 of the Aged Care Act 1997; and
(b) the co-payment does not exceed the amount the approved provider is permitted to charge the POW or VC recipient under any agreement between the Secretary of the Department that administers the Aged Care Act 1997 and the approved provider pursuant to section 15.33 of the Flexible Care Subsidy Principles 1997.
10.9.3 In deciding whether to accept financial responsibility for transition care (care) provided to a POW or VC recipient the Commission should take into account:
(a) whether the care was provided in accordance with the relevant provisions of the Aged Care Act 1997 and the relevant instruments thereunder;
Note 1: Part 3.3 of Chapter 3 of the Aged Care Act 1997 deals with transition care (flexible care)
Note 2: The Approval of Care Recipients Principles 1997, the Flexible Care Subsidy Principles 1997 and the User Rights Principles 1997 are relevant to transition care (flexible care).
(b) whether the care complies with:
(i) any agreement between the approved provider of the care and the Secretary of the Department that administers the Aged Care Act 1997 — under the Aged Care Act 1997 and under 15.33 of the Flexible Care Subsidy Principles 1997; and
(c) whether, if there is an agreement mentioned in (b)(i) and the agreement (Provider/Secretary Agreement) sets out requirements for agreements (client agreement) between an approved provider and a recipient of flexible care or flexible care that is transition care:
(i) the client agreement satisfies any requirements in respect of it in the Provider/Secretary Agreement; and
(ii) the provision of care complies with the client agreement.
(d) whether the care essentially duplicates treatment the POW or VC recipient is receiving under other provisions of the Principles (double-dipping).
10.10 Billing
10.10.1 An approved provider should bill the Department of Human Services for the co-payment for transition care, rather than the POW or VC recipient (client) but if the client is billed, the Commission may, subject to 10.9.2 and 10.9.3, accept financial responsibility for the amount.