PART 1 — INTRODUCTION/COMMENCEMENT

1.1.1 The Treatment Principles, prepared by the Repatriation Commission under section 90 of the Act, set out the circumstances in which, and conditions subject to which, treatment may be provided for eligible persons under Part V of the Act and are to be read subject to the Act.

1.1.2 The Treatment Principles state the rules under which the Repatriation Commission may arrange, or accept financial responsibility for the cost of, treatment for persons eligible for treatment under the Act.

Note: Consistent with the Act, treatment extends beyond medical treatment and also encompasses social and domestic assistance.

1.2 Application of Repatriation Private Patient Principles

1.2.1 The Repatriation Private Patient Principles (the RPPPs), determined by the Commission under section 90A 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 that they apply.

1.2.2 A provision of the Treatment Principles does not apply if it is inconsistent with the RPPPs.

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

1.3 Delegation

1.3.1 The Commission may delegate all or any of its powers under the Principles (except this power of delegation) in the same manner, and subject to the same conditions, that it may delegate all or any of its powers under the Act.

Note: section 213 of the Act sets out the circumstances in which the Commission may delegate its powers.

1.4 Interpretation

1.4.1 In these Principles, unless a contrary intention appears:

“ABN (Australian Business Number)” has the meaning given by the A New Tax System (Australian Business Number) Act 1999.

“Aboriginal and/or Torres Strait Islander Primary Health Care worker” means a person who is qualified as an Aboriginal and/or Torres Strait primary health care worker after undertaking a course in Aboriginal and/ or Torres Strait Islander Health, provided by an institution recognised by the Aboriginal and Torres Strait Health Islander Practice Board of Australia as suitable for providing a course of that nature, and who obtained a Certificate Level III (or higher) under the course.

“Aboriginal and/or Torres Strait Islander Health Worker Care

Co‑ordination treatment” means treatment provided by an Aboriginal and/or Torres Strait Islander Primary Health Care worker to an entitled person under the Coordinated Veterans' Care Program, comprised of:

(a) implementing the Comprehensive Care Plan for the person under the Program — in particular co‑ordinating treatment services under the Comprehensive Care Plan;

(b) liaising, in relation to the Comprehensive Care Plan, with the general practitioner who manages the Comprehensive Care Plan for the person;

(c) performing such other functions under the program that the Aboriginal and/or Torres Strait Islander Primary Health Care worker has under the Fees for Coordinated Veterans' Care Program Providers.

“ACPMH treatment” means action taken with a view to maintaining an entitled veteran in mental health and includes:

(a) training members of the Defence Force or staff made available under section 196 of the Act, or both, in the mental health care disciplines that could benefit the mental health of an entitled veteran; and

(b) conducting research into mental injuries or diseases suffered by members of the Defence Force or into the mental state generally of such members with the resulting knowledge being applied to the benefit of the health of an entitled veteran; and

(c) improving communication on mental injury or disease health care matters between:

(i) members of the Defence Force who are staff‑managers; and

(ii) staff made available under section 196 of the Act; and

(iii) an entitled veteran; and

(d) conducting mental injury or disease health care policy research with the outcomes of that research being applied to the benefit of the health of an entitled veteran.

Note (1): under subsection 80(1) of the Act treatment can be action taken with a view to maintaining a person in physical or mental health.

Note (2): the terms “member”, “Defence Force”, “member of the Defence Force”, are defined in the Act.

“Act” means the Veterans’ Entitlements Act 1986.

“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.

“admission date” means the date on which a general practitioner records in writing (including in electronic form) that the general practitioner has decided an entitled person may participate in the Coordinated Veterans' Care Program.

“admitting general practitioner”, in relation to an entitled person in the Coordinated Veterans' Care Program, means the general practitioner who decided an entitled person may participate in the Coordinated Veterans' Care Program.

“Aged Care Rules” means the rules, as in force from time to time, made under section 602 of the Aged Care Act 2024.

“AHPRA” means the Australian Health Practitioner Regulation Agency established under section 23 of the Health Practitioner Regulation National Law as in force in a State or Territory.

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

“approved provider” means a State, Territory or Local Government, or incorporated organisation, or person, that has entered into an arrangement with the Commission or the Department for the provision of:

(a) a Home Care service (category A); or

(b) a Home Care service (category B); or

(c) a Home Care service (category C); or

(d) a limited VHC‑type service;

to an entitled person, whether by the approved provider or a sub‑contractor engaged by it.

“assistive communication device” means an object that enhances the ability of a person with complex communication needs to communicate and includes items such as:

 communication books or boards

 speech generating devices

 modified personal computers

 computerised devices, which may include a keyboard and screen display and which may incorporate synthetic speech, memory functions, and word prediction facilities

 devices commonly known as computer tablets and smart `phones.

“Australian Centre for Posttraumatic Mental Health” and “ACPMH” mean the Australian Centre for Posttraumatic Mental Health Incorporated.

“authorised nurse practitioner” has the meaning it has in subsection 84(1) of the National Health Act 1953.

“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) has appropriate qualifications in clinical psychology and practises as a clinical psychologist.

Note: an example of an appropriate qualification would be completion of 2 years of formal, post‑graduate (Masters level) clinical training in an accredited, university based program and completion of 2 more years supervised clinical training as well as continuing education on an annual basis.

“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.

“Commonwealth Home Support Programme service” means a service provided to a person under the programme administered by the Department of Health called the “Commonwealth Home Support Programme” and includes any service provided under that programme as the name of the programme may change from time to time.

“community nurse” means a registered nurse or enrolled nurse who works in a community nursing setting and who is employed or engaged by a community nursing provider.

“Community Nurse Care Co‑ordination treatment” means

treatment provided by a community nurse to an entitled person under the Coordinated Veterans' Care Program, comprised of:

(a) implementing the Comprehensive Care Plan for the person under the Program — in particular co‑ordinating treatment services under the Comprehensive Care Plan; and

(b) liaising, in relation to the Comprehensive Care Plan, with the general practitioner who manages the Comprehensive Care Plan for the person.

“community nursing provider” means a community nursing provider who has entered into an agreement with the Commission to provide community nursing services to entitled persons.

“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.

“compensable patient” means a person who has established, or is likely to establish, an entitlement to damages or compensation from, or has commenced an action for damages against, another party that is not a registered health insurance organisation or a friendly society, for treatment of an injury, disease or other medical condition.

“Comprehensive Care Plan” means the care plan prepared by a general practitioner, in accordance with the Notes for Coordinated Veterans' Care Program Providers, for an entitled person participating in the Coordinated Veterans' Care Program.

Note: Fees for the preparation of a “Comprehensive Care Plan” are set out in the Schedule 8, Co‑ordinated Veterans’ Care (CVC) Program of the Department of Veterans’ Affairs Fee Schedules for Medical Services (see: paragraph 3.5.1).

“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:

(c) premises conducted by or on behalf of the State;

(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 care and welfare of eligible persons.

“convalescent care” means a period of medically prescribed convalescence for an entitled person who is recovering from an acute illness or an operation.

“Coordinated Veterans’ Care Program” means the treatment program of that name set out in Part 6A of these Principles and in the Notes for Coordinated Veterans' Care Program Providers that aims to reduce the need for hospitalisation among Gold Card holders and eligible White Card holders of the veteran and defence force community and improve their social well‑being. In particular the program has the following main features:

 assessment – a general practitioner (GP) will assess a person with complex care needs due to chronic disease to see if the person would benefit from the clinical care services under the program and ascertain if the person meets the program’s eligibility criteria;

 consent – a person needs to consent to participation in the program and the GP needs to record that consent. As treatment is being provided it is the GP’s responsibility to ensure a potential participant in the program understands the nature of the program and that the person’s personal details that are relevant to the person’s treatment under the program may be provided to bodies and individuals such as the Department, the Department of Human Services and health care providers, who have a need for the information in connection with the person’s treatment under the program;

 care plan – the GP will prepare a Comprehensive Care Plan for a person the GP admits to the program;

 consultation – the person will be consulted in the preparation of the care plan and its review;

 implementation and co‑ordination – the GP’s practice nurse (or a community nurse via a DVA‑contracted community nursing provider, or an Aboriginal and/or Torres Strait Islander Primary Health Care worker, if more appropriate) will implement the care plan and, in particular, co‑ordinate services under the plan.

“Coordinated Veterans' Care Program treatment” means:

(a) GP Care Leadership treatment; or

(b) Practice Nurse Care Co‑ordination treatment; or

(c) Community Nurse Care Co‑ordination treatment; or

(d) Aboriginal and/or Torres Strait Islander Health Worker Care Co‑ordination treatment.

“co payment”, in relation to the Veterans’ Home Care Program, means an amount of money an approved provider or a sub‑contractor is permitted to charge an entitled person, pursuant to an arrangement between the approved provider and the Commission, in respect of a Home Care service (category A).

“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 Act.

“daily care fee” 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 (including a former prisoner of war or a person awarded the Victoria Cross) who is receiving, or received, residential care—the maximum daily amount of the resident contribution for the person worked out under section 277 of the Aged Care Act 2024; or

(c) in relation to an entitled person (including a former prisoner of war or a person awarded the Victoria Cross) who is in a class referred to in section 275A of the Aged Care Act 2024 and is receiving, or received, residential care—the maximum daily amount of the transitional resident contribution worked out under section 285A‑10 of the Aged Care Rules; or

(d) in relation to an entitled person (including a former prisoner of war or a person awarded the Victoria Cross) who is receiving, or received, residential care (respite)—the amount of resident respite fee for the person worked out under subsection 283(2) of the Aged Care Act 2024.

“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 who has a general registration in the dental hygienists division under the National Law in the dental profession.

“dental therapist” means a person who has a general registration in the dental therapists division under the National Law in the dental profession.

“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

(c) has been recognised as a specialist in the particular field by:

(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.

“determined condition” means any injury, disease, condition, or symptom of a condition (whether the condition is identifiable or not) that may be treated under and subject to these Principles, pursuant to, and subject to, a determination under section 88A or 88B of the Act.

“determined residential care condition” means a determined condition in respect of which Commission‑funded treatment is available solely by reason of section 6 of the Veterans’ Affairs (Extended Eligibility for Treatment) Instrument 2015 made under section 88A of the Act.

Note: Section 6 of the Veterans’ Affairs (Extended Eligibility for Treatment) Instrument 2015 extends Commission‑funded residential care to a non‑war caused etc condition of veterans with a White Card ("the determined condition"). Unless that determined condition attracts other Commission‑funded treatment pursuant to another determination under section 88A of the Act, it may receive Commission‑funded residential care only and not Commission‑funded medical treatment or dental treatment etc.

“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 diabetes educator to a person with diabetes.

“Domestic Assistance” means the service under the Veterans' Home Care Program consisting of:

(a) assistance with domestic chores, including assistance with cleaning, dishwashing, clothes washing and ironing, shopping and bill paying; and

(b) help with meal preparation where this is not the primary focus of the occasion of the service; and

(c) in remote areas, activities such as collecting firewood.

“DRCA” means the Safety, Rehabilitation and Compensation (Defence‑related Claims) Act 1988.

“DRCA disability” means an injury (within the meaning of the Safety, Rehabilitation and Compensation (Defence‑related Claims) Act 1988):

(a) for which the Military Rehabilitation and Compensation Commission has accepted liability to pay compensation under that Act; and

(b) for which the person with the injury is eligible to be provided with treatment under Part V of the Act.

Note 1: In the Safety, Rehabilitation and Compensation (Defence‑related Claims) Act 1988 the definition of injury includes a disease (see section 5A of that Act).

Note 2: Section 85(2A) of the Act provides eligibility for treatment of a person with an injury under the Safety, Rehabilitation and Compensation (Defence‑related Claims) Act 1988.

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

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

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

“eligible person” has the same meaning that it has in subsection 90(8) of 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.

"emergency short term home relief" means care provided to an entitled person in his or her home on the following conditions:

(a) the person or the person's carer is unable to provide care due to sudden and unforeseen circumstances; and

(b) the period for which the care is provided does not exceed 72 hours (episode) per emergency except that, if the entitled person requires further care within 24 hours after the end of the previous episode in an emergency, and obtains prior approval, a further episode of care (up to 72 hours) may be provided in that emergency; and

(c) the cumulative period of the care provided to the entitled person did not exceed 216 hours in a Financial year.

Note: emergency short term home relief is not relevant to the calculation of the daily care fee for residential care or residential care (respite).

“enrolled nurse” means a person who is registered under a law of a State or Territory or of the Commonwealth to practise as an enrolled nurse.

“entitled person” means a person who is:

(a) an entitled veteran; or

(b) an entitled widow; or

(c) an entitled widower; or

(d) a child eligible for treatment under section 86 of the Act, but not a child who is eligible only under sub‑section 86(5) of the Act; or

(e) subject to the terms of any determination under section 88A of the Act, a former child of a veteran who is eligible for treatment in accordance with a determination under section 88A of the Act; or

Note (1): "child" under the Act has a different meaning to its normal meaning and means a person who has not turned 16 or, in the case of a child receiving full‑time education, has not turned 25. Accordingly a child of a veteran ceases to be a child of the veteran upon turning 16 or 25, as the case may be. The child is, therefore, a former child of the veteran.

Note (2): this paragraph is relevant to the provision of limited VHC‑type services to former children of veterans receiving the Veterans' Home Care services of Domestic Assistance and Home and Garden Maintenance. See also Determination 7/2001.

(f) subject to the terms of any determination under section 88A of the Act, a dependant of a veteran who is the partner of the veteran or

Note: this paragraph is relevant to the provision of limited VHC‑type services to partners of entitled veterans receiving the Veterans' Home Care services of Domestic Assistance and Home and Garden Maintenance. See also Determination 7/2001.

(g) a person with a DRCA disability.

“entitled veteran” means:

(a) a person who is eligible for treatment under section 85 of the Act, but not a person who is eligible only under subsection 85(9) of the Act; or

(b) subject to the terms of any determination under section 88A or 88B of the Act, a veteran who is eligible for treatment in accordance with a determination under section 88A or 88B of the Act.

Note 1: subsection 85(9) concerns Vietnam veterans requiring urgent treatment for any disease or injury, whether war‑caused or not. See also principle 2.5.

Note 2: section 88A of the Act enables the Commission to determine a class of veterans to be eligible for specified treatment.

Note 3: section 88B of the Act enables the Commission to determine a class of persons to be eligible for treatment, being treatment that is the provision of services under the program established by the Commonwealth and known as the Veteran Suicide Prevention pilot.

(c) a person with a SRCA disability.

“entitled widow” or “entitled widower” means a person who is eligible for treatment under subsection 86(1) or 86(2) of the Act or, subject to the terms of any determination under section 88A of the Act, a person who is a widow or widower who is eligible for treatment in accordance with a determination under section 88A of the Act.

Note: section 88A of the Act enables the Commission to determine a class of veterans, or current or former dependants of veterans, to be eligible for specified treatment.

"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:

(c) every time a service provider sees a new patient; or

(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 DVA‑contracted community nursing provider.

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.

“excluded service” means:

(a) a HACC Review Agreement (National Partnership) service; or

(b) a Commonwealth Home Support Programme service;

that is the same type of service that may be provided under the Veterans’ Home Care Program as a Home Care service (category A) or Home Care service (category C).

Note : the intention is that a Home Care service (category A), Home Care service (category B) and Home Care service (category C) are mutually exclusive.

“exempt amount” means an amount of money not payable by an entitled person in respect of any Home Care service (category A) or Home Care service (category C) provided to the entitled person by an approved provider, because the entitled person is an exempt entitled person.

“exempt entitled person” means, in relation to the provision of any Home Care service (category A) or Home Care service (category C) to an entitled person, an entitled person who:

(a) has a dependent child; or

Note: dependent child is defined in the Act as having the same meaning as in the Social Security Act. Note also that under the Acts Interpretation Act 1901 the singular includes the plural meaning a person can have more than one dependent child.

(b) is a person to whom section 52Y of the Act applies; or

Note: the application of section 52Y to a person means the person avoids severe financial hardship.

(c) is in receipt of an income support payment at the maximum rate and does not earn, derive or receive ordinary income exceeding $40 per fortnight; or

(d) in the opinion of the Commission, could suffer severe hardship if the person was to make a payment in respect of the service.

Note: the Commission may allow exemption from payment for a period or until the

occurrence of an event.

“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.

“general practitioner” has the same meaning as “general practitioner” has in the Health Insurance Act 1973.

“Gold Card” means the identification card (also known as the Veteran Card) provided by the Department to a person who is eligible under the Act for treatment, subject to these Principles, for all injuries or diseases.

“GP Care Leadership treatment” means treatment provided by a general practitioner to an entitled person, under the Coordinated Veterans' Care Program, comprised of the following:

(a) preparing and managing the Comprehensive Care Plan for the person under the Program;

(b) overseeing a practice nurse in the implementation of the Comprehensive Care Plan — where a practice nurse and not a community nurse or Aboriginal and/or Torres Strait Islander Primary Health Care worker or the general practitioner co‑ordinates treatment under the Comprehensive Care Plan (Practice Nurse Care Co‑ordination treatment);

(c) referring the person to a DVA‑contracted community nursing provider for Community Nurse Care Co‑ordination treatment or to an Aboriginal and/or Torres Strait Islander Primary Health Care worker for Aboriginal and/or Torres Strait Islander Health Worker Care Co‑ordination treatment, if appropriate;

(d) performing such other functions under the program that the general practitioner has under the Notes for Coordinated Veterans' Care Program Providers.

“GP Home Care service (category C) Referral” means treatment comprised of a general practitioner preparing a written document that refers an entitled person, who the general practitioner has admitted to and is treating under the Coordinated Veterans' Care Program, to a VHC assessment agency for assessment for a Home Care service (category C) under the Veterans’ Home Care Program and which:

(a) is in the form, if any, approved by the Commission; and

(b) is sent to the VHC assessment agency, including as a facsimile message.

“HACC Review Agreement (National Partnership) service” means a service of home or community care that could be, or could have been, provided to a person under an agreement between the Commonwealth and a State or the Northern Territory — being an agreement made under the Home and Community Care Act 1985 but deemed to be a National Partnership Agreement in the context of the Intergovernmental Agreement on Federal Financial Relations of 2008, made under the Federal Financial Relations Act 2009.

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

“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:

(c) a hospital; or

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

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

“Home and Community Care Program service” means a service provided to a person under the auspices of the Home and Community Care Act 1985 when that Act was in force.

Note: in 2015 there was a proposal to repeal the Home and Community Care Act 1985 by the Omnibus Repeal Day (Spring 2014) Act 2014.

“Home and Garden Maintenance” means the service, under the Veterans' Home Care Program, of maintaining the home, garden or yard of an entitled person, and includes:

(a) assistance with minor maintenance and minor repair of the home (e.g changing light bulbs, minor carpentry, minor painting, replacing tap washers, but not the supply of replacement items), garden or yard to keep the home, garden or yard safe and habitable;

(b) lawn mowing;

but does not mean:

(c) tree felling or tree removing or other major tasks related to a garden or yard;

(d) provision of materials.

Note: recipients of Veterans' Home Care services will be expected to supply materials used in home maintenance, eg replacement light bulbs and tap washers. Service providers will be required to provide any equipment needed, eg garden tools.

“home care” means a funded aged care service (within the meaning of the Aged Care Act 2024) that is in the service group referred to in paragraph 8(3)(a) of that Act.

“Home Care service (category A)” means the provision of Domestic Assistance, Personal Care, Home and Garden Maintenance or Respite Care to an entitled person pursuant to the Veterans' Home Care Program.

“Home Care service (category B)” means:

(a) for an entitled person in Victoria or Western Australia at a time when the Commonwealth Home Support Programme service in Victoria or Western Australia, as the case may be, does not include a service that would satisfy the description of a HACC Review Agreement (National Partnership) service — the provision of treatment to the person pursuant to the Veterans' Home Care Program that would satisfy the description of:

(i) a HACC Review Agreement (National Partnership) service ;or

(ii) a Commonwealth Home Support Programme service other than such a service that would satisfy the description of a HACC Review Agreement (National Partnership) service; or

(ii) both services in (i) and (ii);

but does not mean the provision of treatment pursuant to the Veterans' Home Care Program that would satisfy the description of an excluded service; or

(b) for an entitled person in a State or Territory at a time when the Commonwealth Home Support Programme service in the State or Territory in which the person is in includes a service that would satisfy the description of a HACC Review Agreement (National Partnership) service — the provision of treatment to the person pursuant to the Veterans' Home Care Program that would satisfy the description of a Commonwealth Home Support Programme service but does not mean the provision of treatment pursuant to the Veterans' Home Care Program that would satisfy the description of an excluded service.

Note 1: as at 1 July 2015 some services under the Commonwealth Home Support Programme (CHSP) (generally speaking CHSP services are a Home Care service (category B)) were not provided in Victoria or Western Australia. The services in question are known as “HACC services”. HACC services are home or community care services that were originally provided under agreements under the Home and Community Care Act 1985 (the HACC Act) except in Victoria and Western Australia where similar services were provided under Bilateral Agreements with the Commonwealth Government. At or about 2008/2009 HACC services in States/Territories (except Victoria/Western Australia) were provided under agreements known as “National Partnership Agreements”. The National Partnership Agreements were made under the auspices of the Intergovernmental Agreement on Federal Financial Relations of 2008 and the Federal Financial Relations Act 2009. In short, the original agreements under the HACC Act were deemed to be National Partnership Agreements and the HACC Act was rendered obsolete. On 1 July 2015, in all States/Territories except Victoria/Western Australia, HACC services ceased being provided under National Partnership Agreements and were provided under CHSP. However as at 1 July 2015 HACC‑type services in Victoria/Western Australia continued to be provided under the Bilateral Agreements between those States and the Commonwealth.

Note 2: the intention of paragraph (a) of this definition is to enable the Department of Veterans’ Affairs (DVA) to pay for HACC services for an entitled person in Victoria and Western Australia in addition to paying for services for the person under the Commonwealth Home Support Programme service until the Commonwealth Home Support Programme applies fully in those States and includes the HACC services. The intention in paragraph (b) of this definition is that where the Commonwealth Home Support Programme operates fully in Australia i.e. includes HACC services, DVA will only pay, under this definition, for services under the Commonwealth Home Support Programme. There is to be no potential for double‑dipping.

“Home Care service (category C)” means the provision by an approved provider of a service to an entitled person under the Veterans’ Home Care Program that is:

(a) pursuant to a GP Home Care service (category C) Referral and allocated to the provider by a VHC assessment agency; and

(b) aimed at reducing the person’s social isolation by improving their social networks; and

(c) provided to an entitled person by an approved provider.

“Human Services Department” means a Department, or Executive Agency, administered by the Minister administering the Human Services (Centrelink) Act 1997.

"income support payment" has the same meaning it has in the Social Security Act 1991, save that it includes an income support supplement under the Act.

Note: As at 1 January 2001 income support payments were:(a) a social security benefit; (b) a job search allowance; (c) a social security pension; (d) a youth training allowance; (e) a service pension.

“in‑home respite” means care provided to a person in his or her own home for a maximum of 196 hours in a Financial year to provide rest or relief from the role of caring:

(a) to the person; or

(b) to the person’s carer.

Note: in‑home respite is not relevant to the calculation of the daily care fee for residential care or residential care (respite).

“inpatient” means a person formally admitted for treatment by a hospital.

“institution”, in Part 11:

(a) includes a retirement village; and

(b) a cluster of self‑care units.

Note: retirement village is defined in section 5M of the Act and the intention is that the power of the Commission in subsection 5M(4) to determine premises have the same function as a retirement village, for the purposes of the Act, applies for the purposes of the Part 11 of the Principles.

“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

(c) does not require general anaesthesia; and

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

“MRCA” means the Military Rehabilitation and Compensation Act 2004.

“MRCC” means the Military Rehabilitation and Compensation Commission established under the MRCA.

“National Law” has the same meaning as in section 3 of the Health Insurance Act 1973.

“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 Human ServicesDepartment, 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 referred to 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 Coordinated Veterans' Care Program Providers” means the document approved by the Commission or a member thereof, or by the Secretary to the Department, entitled “Notes for Coordinated Veterans' Care Program”, and referred to in Schedule 1, that sets out the terms on which:

(a) a general practitioner;

(b) a practice nurse;

(c) a community nurse (via a DVA‑contracted community nursing provider); and

(d) an Aboriginal and/or Torres Strait Islander Primary Health Care worker;

is to provide treatment to an entitled person under the Coordinated Veterans' Care Program in order for the Commission to accept financial responsibility for that treatment.

“Notes for General Practitioners” means the document that:

(a) is approved by the Commission or a member thereof, or by the Secretary to the Department, entitled “Notes for General Practitioners”; and

(b) is referred to in Schedule 1; and

(c) sets out the terms on which, and the conditions subject to which, a general practitioner 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 general practitioner and the Commission or the Department.

“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 referred to 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.

“nursing‑home‑type care” means the treatment described in paragraph 9.3 of the Principles.

“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 Human ServicesDepartment, 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.

“optical dispenser”, in the case of an individual, means a person who:

(a) interprets optical prescriptions and fits and services optical appliances such as spectacle frames and lenses; and

(b) holds a qualification that, in the opinion of the Commission, is appropriate for the skills needed to practise optical dispensing; and

(c) is a member of a body established to supervise the occupation of optical dispenser; and

(d) holds a provider number as an optometrist, ophthalmologist, orthoptist or optical dispenser.

“optical dispenser”, in the case of a company, means a company that:

(a) holds an ABN (Australian Business Number);

(b) carries on a business of optical dispensing;

(c) employs or engages for the optical dispensing aspects of the business — an individual who is an optical dispenser.

“optical dispensing” means interpreting optical prescriptions and fitting and servicing optical appliances such as spectacle frames and lenses.

“oral health therapist” means a person who has general registration in the oral health therapists division under the National Law in the dental profession.

"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 Veterans' Entitlements Act 1986.

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

“outreach program counselling” means the treatment of that name established by paragraph 7.7A.1 of the Principles — comprised of mental health counselling under the Veterans and Veterans Families Counselling Service provided by an outreach program counsellor to a person eligible for the treatment under the Principles.

“outreach program counsellor” means:

(a) a person who is registered with AHPRA to practise as a psychologist;

(b) a person who is registered with AHPRA to practise as an occupational therapist;

(c) a person who is registered with AHPRA to practise as a registered nurse;

(d) a person who is eligible for membership with the Australian Association of Social Workers (ABN 93 008 576 010);

(e) a person who is registered:

(i) as a registered clinical counsellor with the Psychotherapy and Counselling Federation of Australia (ABN 91 794 316 901); or

(ii) at registration category Level 3 or Level 4 with the Australian Counselling Association Limited (ABN 12 242 711 378):

being a person approved by the Department or the Commission to provide outreach program counselling under Part 7.7A.

"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;

(c) the proposed management of the injury or disease; and

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

“period of care” in relation to the care provided by:

(a) a general practitioner; or

(b) a practice nurse; or

(c) an Aboriginal and/or Torres Strait Islander Primary Health Care worker; or

(d) a community nurse (via a DVA‑contracted community nursing provider);

to an entitled person under the Coordinated Veterans' Care Program (Program), means the period set out in the Notes for Coordinated Veterans' Care Program Providers in relation to the general practitioner, practice nurse, community nurse or Aboriginal and/or Torres Strait Islander Primary Health Care worker, provided that any subsequent period of care by the same general practitioner is approved by the general practitioner for the person.

“Personal Care” means the service under the Veterans' Home Care Program consisting of assistance with daily self care tasks, such as eating, bathing, toileting, dressing, grooming, getting in and out of bed, and moving about the house.

“PBS” means the Pharmaceutical Benefits Scheme authorised under the National Health Act 1953.

“physiotherapy” includes hydrotherapy.

“practice nurse” means a registered nurse or enrolled nurse employed or engaged by a general practitioner as a nurse in the practice of the general practitioner.

“Practice Nurse Care Co‑ordination treatment” means

treatment provided by a practice nurse to an entitled person, under the Coordinated Veterans' Care Program, comprised of:

(a) implementing the Comprehensive Care Plan for the person under the Program — in particular co‑ordinating treatment services under the Comprehensive Care Plan;

(b) liaising, in relation to the Comprehensive Care Plan, with the general practitioner supervising the practice nurse in relation to the implementation of the Comprehensive Care Plan;

(c) performing such other functions under the program that the practice nurse has under the Notes for Coordinated Veterans' Care Program Providers.

“practitioner” has the same meaning as in section 124B of the Health Insurance Act 1973 in force from time to time.

“Principles” means this instrument.

“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.

“prisoner of war” includes a person who, as a civilian, was detained by the enemy during World War 2 ‑ but being a civilian within the meaning of “eligible civilian” in the Act.

“private health insurer” has the meaning it has in the Private Health Insurance Act 2007.

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

"proscribed amount" means, in relation to the Veterans' Home Care Program:

(a) subject to paragraph (b), an amount of money that if paid by an entitled person would mean the entitled person has paid in respect of a Home Care service (category A) comprised of Domestic Assistance provided to that entitled person by any approved provider or by any sub‑contractor during a week or part thereof, an amount exceeding $5;

Note: for the purpose of ascertaining if an amount of money is a proscribed amount where the amount demanded, received or assigned is in respect of a service (s) provided during two or more weeks, without the service (s) being related to the particular week in which the service(s) was delivered, the amount shall be apportioned pro rata to those weeks.

(aa) subject to paragraph (b), an amount of money that if paid by an entitled person would mean the entitled person has paid in respect of a Home Care service (category A) comprised of Home and Garden Maintenance, provided to that entitled person by any approved provider or by any sub‑contractor during the relevant period referred to in paragraph 7.3A.3 (2) of the Principles, an amount exceeding $75;

Note (1): the "relevant period" is a period of 12 months.

Note (2): under paragraph 7.3A.8(a) of the Principles, an entitled person cannot be charged more than $5 per hour of service.

(b) an amount of money that if paid by an entitled person receiving a Home Care service (category A) that was similar to a Home and Community Care Program service provided to the person immediately before 1 January 2001 would mean the entitled person has paid in respect of the Home Care service (category A) provided to that entitled person by any approved provider or by any sub‑contractor, an amount exceeding the maximum amount the person could have been required to pay over a particular period in respect of the Home and Community Care Program service formerly provided to the person that was similar to the Home Care service (category A) provided to the entitled person;

Note: for the purpose of ascertaining if an amount of money is a proscribed amount where the amount demanded, received or assigned is in respect of a service (s) provided during two or more weeks, without the service (s) being related to the particular week in which the service(s) was delivered, the amount shall be apportioned pro rata to those weeks.

(c) subject to paragraph (b), an amount of money that if paid by an entitled person would mean the entitled person has paid, in respect of a Home Care service (category A) comprised of Personal Care provided to that entitled person by any approved provider or by any sub‑contractor during a week or part thereof, an amount exceeding $10;

Note: for the purpose of ascertaining if an amount of money is a proscribed amount where the amount demanded, received or assigned is in respect of a service (s) provided during two or more weeks, without the service (s) being related to the particular week in which the service(s) was delivered, the amount shall be apportioned pro rata to those weeks.

(d) an amount of money in respect of Respite Care provided, or to be provided, by an approved provider or by a subcontractor, to an entitled person;

Note: the intention is that any amount charged for Respite Care is a proscribed amount regardless of whether it would or would not exceed $5 per hour of service.

(e) an amount of money in respect of a Home Care service (category A) provided or to be provided to an entitled person that was a similar service to a Home and Community Care Program service the entitled person received immediately before 1 January 2001 and in respect of which the entitled person had not been required to pay a charge;

Note: the intention is that any amount charged for a service similar to a free former Home and Community Care Program service previously received is a proscribed amount regardless of whether it would or would not exceed $5 per hour of service.

(f) an amount of money, in respect of a Home Care service (category A) provided or to be provided to an entitled person that was a similar service to a Home and Community Care Program service the entitled person received immediately before 1 January 2001, that exceeds any amount of money the entitled person had been required to pay in respect of the Home and Community Care Program service;

Note: It is the intention that any amount charged for a service similar to a Home and Community Care Program service previously received that is over and above the amount the entitled person previously paid in respect of the Home and Community Care Program service is a proscribed amount notwithstanding that the sum of the amounts that could and could not be charged did not exceed $5 per hour of service. The limitation on the maximum amount a person could be required to pay in (a), (aa) and (b) above applies to this situation (maximum amount payable over a period).

(g) an exempt amount;

Note: the intention is that an exempt amount remains a proscribed amount and therefore not chargeable notwithstanding it would or would not exceed $5 per hour of service.

“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.

“provision of a Home Care service (category A) to an entitled person by an approved provider” includes the situation where an approved provider engages a sub‑contractor to provide a Home Care service (category A) to an entitled person.

“provision of a Home Care service (category B) to an entitled person by the Commission” includes the situation where the Commission engages a sub‑contractor to provide a Home Care service (category B) to an entitled person.

“provision of a Home Care service (category C) to an entitled person by an approved provider” includes the situation where an approved provider engages a sub‑contractor to provide a Home Care service (category C) to an entitled person.

“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 thereof, or by the Secretary to the Department, and referred to 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 thereof, or by the Secretary to the Department, and referred to 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.

“registered nurse” means a person who is registered under a law of a State or Territory or of the Commonwealth to practise as a registered nurse.

“registered provider” has the meaning given in subsection 11(2) of the Aged Care Act 2024.

“Repatriation Pharmaceutical Benefits Card” means the identification card entitled 'Repatriation Pharmaceutical Benefits Card' which is provided to a person pursuant to a determination under section 93X of the Act and which entitles the person to pharmaceutical benefits in accordance with the Repatriation Pharmaceutical Benefits Scheme.

Note: Part VA of the Act extends pharmaceutical benefits to eligible Commonwealth veterans, eligible allied veterans and to eligible allied mariners.

“Repatriation Pharmaceutical Benefits Scheme” means Part I of the Scheme made under section 91 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 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:

(c) care provided to a person in the person’s private home; or

(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 facility” means a facility in which residential care is provided to a person.

“residential care (respite)” means residential care provided as respite and includes residential care (28 day respite).

“residential care (28 day respite)” means residential care provided as respite for up to 28 days in a Financial year pursuant to the Veterans' Home Care Program.

“residential care subsidy” means a subsidy worked out under Division 4 or Division 4A of Part 2 of Chapter 4 of the Aged Care Act 2024.

“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 Care” means the service under the Veterans' Home Care Program consisting of in‑home respite, residential care (28 day respite) or emergency short term home relief.

Note: by virtue of Determination 4/2001 made under section 88A of the Act, "Respite Care" may be applied in respect of all conditions of a white‑card holder ‑ not just for war‑caused conditions.

“respite care in an institution” means care provided as respite to a person in an institution.

“revoked Treatment Principles” means the legislative instrument known as the Treatment Principles (2004 No. R8) made under section 90 of the Act.

“Rural Enhancement Scheme” means the scheme established by the Commission under subsection 84(1) of the Act, in consultation with the Australian Medical Association Ltd, and which has the following features:

(a) general practitioners 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 general practitioners 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.

“RPPPs” means the Repatriation Private Patient Principles determined by the Commission under section 90A of the Act.

“specialist aged care program” has the meaning given in section 7 of the Aged Care Act 2024.

“speech pathologist”, for the purposes of the Principles, is a person who:

(a) has been trained to assess and treat people who have complex communication needs; and

(b) has a provider number (i.e. “registered” with the Human ServicesDepartment); and

(c) is not a disqualified health care provider in the terms mentioned in paragraph 7.1B of the Principles.

Note: under paragraph 7.1B a disqualified health care provider is a person whose services would not, under section 19B of the Health Insurance Act 1973, attract a medicare benefit.

“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 Human ServicesDepartment, 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.

“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.

“sub‑contractor” means, in relation to the Veterans' Home Care Program, a State, Territory or Local Government, or incorporated organisation, or person, engaged by an approved provider or the Commission to provide a Home Care service (category A) or a Home Care service (category B) or a Home Care service (category C) to an entitled person.

“subsequent period of care”, in relation to the provision of care by a general practitioner to an entitled person, means a period of care that may be provided by the general practitioner after the expiry of a period of care that has already been provided by the general practitioner to the entitled person.

Note: a subsequent period of care must be approved by the general practitioner (see: 6A.3). A period of care by a general practitioner that is not a “subsequent period of care” would be the first period of care provided to a person under the Coordinated Veterans' Care Program (Program) and the first period of care provided to a person under the Program by a new general practitioner for the person i.e. where the person has changed general practitioners.

“System Governor” has the meaning given in section 7 of the Aged Care Act 2024.

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

“transition care” means a Transition Care Program as defined in section 7 of the Aged Care Act 2024.

“Vertical Platform Lift” means a lift installed adjacent to vertical walls, which travels up and down, with the platform finishing flat against the floor, and the user embarking/disembarking onto an even surface.

“veteran” has the same meaning as it has in sections 80 and 81 of the Act and includes a person with a DRCA disability.

Note: In sections 80 and 81 of the Act, “veteran” means a person:

(a) who is, because of section 7 of the Act, taken to have rendered eligible war service; or

(b) in respect of whom a pension is, or pensions are, payable under subsection 13(6) of the Act, other than a person who is a veteran under paragraph (a) by reason only that the person rendered service as a member of the Forces of a Commonwealth country of a kind described in paragraphs 6(1)(f) or (g) of the Act and was not domiciled in Australia or an external Territory immediately before the person’s appointment or enlistment in those forces.

Section 81 of the Act provides that “veteran” is also to be read as a reference to a “member of the Forces” or a “member of a Peacekeeping Force” as defined in subsection 68(1) of the Act.

“Veterans' Access Payment” means the amount set out in the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services” referred to in Schedule 1 and called the “Veterans’ Access Payment” — being an additional amount payable by the Department to a general practitioner for a medical service provided by the general practitioner to an entitled person in accordance with these Principles and the Notes for General Practitioners.

Note: a Veterans’ Access Payment is an amount additional to any amount otherwise payable by the Department to a general practitioner for a medical service provided by the general practitioner to an entitled person in accordance with these Principles and the Notes for General Practitioners.

“Veterans and Veterans Families Counselling Service” or “VVCS” means the service funded by the Department known as Open Arms – Veterans & Families Counselling.

"Veterans' Home Care Program" means:

(a) the treatment program under which the Commission ensures the provision of care and assistance services to entitled persons who are frail, or who have disabilities, with the aim of maintaining the independence of those people, allowing them to remain in their own home for as long as possible, and reducing avoidable illness and injury, and includes section 7 of the Veterans Affairs (Extended Eligibility for Treatment) Instrument 2015 and Principles made under section 90 of the Act and the arrangements in support thereof; and

(b) the treatment program under which the Commission may ensure the provision of social support services to entitled persons referred to the program under a GP Home Care service (category C) Referral.

“veterans’ supplement”, in relation to an entitled person, means a primary person‑centred supplement or a secondary person‑centred supplement that applies under the Aged Care Act 2024 to the person as a care needs recipient under that Act because the person is a veteran.

Note (1): See sections 196 and 231 of the Aged Care Act 2024.

Note (2): The Aged Care Rules may specify, in respect of a veterans’ supplement, the circumstances in which the supplement will apply.

“VHC assessment agency” means a person to whom the Commission has delegated its power to:

(a) assess whether a person is suitable for:

(i) a Home Care service (category A); or

(ii) a Home Care service (category B); or

(iii) a Home Care service (category C;

under the Veterans’ Home Care Program; and

(b) allocate a service in (a) to an approved provider.

“Victoria Cross” includes the Victoria Cross for Australia.

“Vietnam veteran” means a veteran who, while a member of the Defence Force, rendered continuous full‑time service outside Australia in the area described in item 4 or 8 of Schedule 2 (in column 1) to the Act while that area was an operational area, whether or not the veteran rendered that service:

(a) as a member of a unit of the Defence Force that was allotted for duty; or

(b) as a person who was allotted for duty.

“VVCS OPC Provider Notes” means the document approved by the Commission or a member thereof, or by the Secretary to the Department, “ Veterans and Veterans Families Counselling Services Outreach Program Counsellors Provider Notes”, and referred to in Schedule 1, that sets out the terms on which an outreach program counsellor is to provide outreach program counselling to an eligible entitled person.

“war‑caused” is to be read as including “defence‑caused” by force of section 81 of the Act; and in relation to a person with a DRCA disability means the person’s injury (within the meaning of the Safety, Rehabilitation and Compensation (Defence‑related Claims) Act 1988) was caused by, or arose out of, the person’s employment in the Defence Force that is covered by the Safety, Rehabilitation and Compensation (Defence‑related Claims) Act 1988.

Note: in the Safety, Rehabilitation and Compensation (Defence‑related Claims) Act 1988the definition of injury includes a disease (see section 5A of that Act).

“week” means the period from Sunday to Saturday, inclusive.

“White Card” means the identification card (also known as the Veteran Card) provided by the Department to a person who is eligible under the Act for treatment, subject to these Principles and any determination under section 88A or 88B of the Act, for one or more of the following conditions:

(a) a determined condition (other than an unidentifiable condition);

(b) a DRCA disability;

(c) a mental health condition;

(d) malignant neoplasia;

(e) pulmonary tuberculosis;

(f) war‑caused injury;

(g) war‑caused disease;

and also means a written authorisation issued on behalf of the Commission under subparagraph 2.1.1(a)(iii) and provided to a person who is eligible under the Act for treatment, subject to these Principles and any determination under section 88A or 88B of the Act, of the following condition:

(h) unidentifiable condition.

Note 1: an "unidentifiable condition" is governed by the Veterans’ Affairs (Extended Eligibility for Treatment) Instrument 2015 (2015 No. R21), as in force from time to time.

Note 2: a “mental health condition” has the same meaning as in the Veterans’ Entitlements (Expanded Access to Non‑Liability Health Care for Mental Health Treatment) Determination 2017 (Instrument 2017 No.R24), as in force from time to time, or in any subsequent legislative instrument, as in force from time to time, that repeals and replaces that determination.

1.4.2 In the Treatment 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.

2.1 Treatment for eligible persons in Australia

2.1.1 Subject to these Principles, the Commission may provide or arrange for treatment in Australia of:

(a) entitled persons who have been issued with:

(i) a Gold Card;or

(ii) a White Card; or

(iii) a written authorisation issued on behalf of the Commission; and

(b) Vietnam veterans and their dependants, who are not otherwise eligible, and who are certified by a medical practitioner as requiring urgent hospital treatment for an injury or disease.

Note: See Principle 2.5 in relation to urgent treatment for Vietnam veterans and their dependants.

2.2 Treatment for entitled persons residing or travelling overseas

2.2.1 Subject to these Principles, the Commission will accept financial responsibility for the treatment overseas of war‑caused injuries or diseases only for:

(a) a veteran who is resident overseas; or

(b) a veteran who is travelling overseas.

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 a war‑caused injury or disease while a veteran is temporarily absent from Australia unless, prior to departure, an office of the Department has been notified of the veteran’s intention to travel.

Financial Limits for Treatment Overseas

Treatment other than residential care/residential care (respite)

2.2.3 Except in an emergency, for treatment other than residential care or residential care (respite), financial responsibility under paragraph 2.2.1 will be limited to:

(a) 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) the cost of treatment provided by a health authority or facility nominated by the Commission.

Treatment that is residential care/residential care (respite)

2.2.4 For treatment that is residential care or residential care (respite), financial responsibility under paragraph 2.2.1 will be limited to:

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

(i) the amount charged the veteran; or

(ii) an amount equal to the amount of residential care subsidy that would be payable if the veteran was in Australia for the same period, plus any daily care fee that the Commission would have accepted responsibility for if the veteran was in Australia;

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

(i) the amount charged the veteran; or

(ii) an amount equal to the amount of residential care subsidy that would be payable if the veteran was in Australia for the same period (not exceeding 63 days in a financial year), plus any daily care fee that the Commission would have accepted responsibility for if the veteran was in Australia.

Note (1): the intention is that the Commission will not accept any further financial responsibility for residential care (respite) provided to a veteran in a financial year where in that year the veteran had already been provided residential care (respite) for 63 days.

Note (2): for the purpose of calculating the number of days for which a veteran was provided with residential care (respite) in a financial year, any day on which the veteran was provided residential care (respite) in Australia in that year is also to be taken into account.

Note (3): A "veteran" includes a former POW. In most, but not all cases, the Commission accepts liability for the daily care fee for former POWs receiving residential care or residential care (respite) but, in the case of entitled persons other than former POWs, who receive residential care (respite), the Commission only accepts liability for the daily care fee for up to 28 days in a Financial year and in the case of residential care being provided to such persons, does not accept liability for any daily care fee.

Note (4): Subject to the Principles, the Commission will not accept financial responsibility for medical or allied‑health treatment applied to the "non‑war caused conditions" (i.e. non‑accepted conditions) of the holder of a Gold Card or White Card residing or travelling overseas.

Note (5): 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 2024 to entitled persons.

Note (6): For the meaning of daily care fee, see paragraph 1.4.1.

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 overseas from Australia where a significant reason for that travel is to obtain treatment or rehabilitation appliances.

2.2.6 Subject to these Principles, the Commission will accept financial responsibility for the treatment of an entitled widow who is resident overseas if her husband had been awarded the Victoria Cross.

2.2.7 Despite paragraph 2.2.1, the Commission will accept financial responsibility for the treatment of entitled persons for any injury or disease

who were residing in Papua New Guinea at the date of independence (16 September 1975) and who have continued to reside there.

Note: Travelling to, or taking up, residence in Papua New Guinea after the date of independence is regarded as travelling to or residing in a foreign country.

No Overseas Veterans' Home Care

2.2.8 The Commission will not accept financial liability for the provision overseas of treatment under the Veterans' Home Care Program.

2.3 Treatment of associated non‑war‑caused injuries or diseases

2.3.1 Subject to these Principles, the Commission will provide, arrange, or accept financial responsibility for treatment of an injury or disease that is not war‑caused to the extent that it is a necessary part of treatment for a war‑caused injury or disease.

2.4 Treatment of malignant neoplasia and pulmonary tuberculosis for veterans

2.4.1 The Commission will provide, or accept financial responsibility for, treatment of a veteran for malignant neoplasia or pulmonary tuberculosis (even if that injury or disease is not war‑caused) on and from the date that is three months before the date on which an application to be provided with that treatment is received at an office of the Department in Australia.

2.4.2 The Commission will provide, or accept financial responsibility for, treatment of a veteran under paragraph 2.4.1 if the treating medical practitioner considers that a malignant neoplasm or pulmonary tuberculosis, as the case may be, is the actual or most likely diagnosis.

2.4.3 Continuing financial responsibility for treatment under paragraph 2.4.1 may be reviewed and may be withdrawn by the Commission if —

(a) the diagnosis is not confirmed to the satisfaction of the Commission within three months from the day on which an application to be provided with that treatment (referred to in subsection 85(2) of the Act) is received at an office of the Department in Australia; or

(b) the Commission is satisfied that the veteran does not suffer, or no longer suffers, any incapacity from a malignant neoplasm or pulmonary tuberculosis.

2.4.4 The Commission will provide or accept financial responsibility for the treatment of other conditions, symptoms, or sequelae resulting from the treatment of malignant neoplasia where it has provided treatment or accepted financial responsibility under paragraph 2.4.1.

2.5 Determination that specified person is eligible for specified kind of treatment

2.5.1 Subject to these Principles, the Commission will accept financial responsibility for treatment of a person eligible for that treatment pursuant to a determination under section 88A or 88B of the Act.

2.5A Treatment of mental health conditions for veterans and ADF members

2.5A.1 The Commission will provide, arrange, or accept financial responsibility for a person who is a veteran or eligible ADF member for the treatment of the person’s mental health condition even if that condition is not a war‑caused or service‑related injury or disease.

2.5A.2 Continuing financial responsibility for treatment for a person under paragraph 2.5A.1 may be reviewed by the Commission at any time after 6 months from the date from which financial responsibility for the person’s treatment is accepted and may be withdrawn by the Commission if —

(a) the person, following a request by the Commission, has failed to provide the Commission with a diagnosis from a psychiatrist, a clinical psychologist or general practitioner for the relevant mental health condition; or

(b) the Commission is otherwise satisfied that the person does not have, or no longer has, the relevant mental health condition.

2.5A.3 The Commission will provide, arrange, or accept financial responsibility for a veteran or eligible ADF member for the reasonable treatment of an injury or disease that is not war‑caused or service‑related to the extent that it is a necessary part of, and is directly associated with, the treatment of the person’s mental health condition in respect of which financial responsibility was provided, arranged or accepted under paragraph 2.5A.1.

2.5A.4 In paragraph 2.5A:

“veteran or eligible ADF member” means a person who is within a class of persons specified in Part 2 of the Veterans’ Entitlements (Expanded Access to Non‑Liability Health Care for Mental Health Treatment) Determination 2017 (Instrument 2017 No. R24), as in force from time to time; or in any subsequent legislative instrument, as in force from time to time, that repeals and replaces that determination; and

“mental health condition” has the same meaning as in the Veterans’ Entitlements (Expanded Access to Non‑Liability Health Care for Mental Health Treatment) Determination 2017 (Instrument 2017 No. R24), as in force from time to time, or in any subsequent legislative instrument, as in force from time to time, that repeals and replaces that determination.

Note: Other matters dealing with the treatment of mental health conditions on a non‑liability basis for veterans and eligible ADF members are dealt with in the Veterans’ Entitlements (Expanded Access to Non‑Liability Health Care for Mental Health Treatment) Determination 2017 (Instrument 2017 No. R24), as in force from time to time, or in any subsequent legislative instrument, as in force from time to time, that repeals and replaces that determination.

2.6 Referrals by the Veterans and Veterans Families Counselling Service

2.6.1 The Veterans and Veterans Families Counselling Service may refer its clients to other counselling services.

2.6.2 The Commission will accept financial responsibility for counselling referred under paragraph 2.6.1 only where that referral is in accordance with guidelines prepared by the Commission.

Note: The guidelines are prepared by the Commission after, and subject to, consideration of advice from the National Advisory Committee on the Veterans and Veterans Families Counselling Service.

2.7A—TRCP treatment (Training, Research, Communication‑improvement, Policy Development for ADF‑Veterans’ etc Health Issues)

2.7A.1 The Commission may accept financial responsibility for TRCP treatment provided by a TRCP provider.

Note (1): under subsection 80(1) of the Act treatment is defined broadly and can include action taken with a view to maintaining a person in physical or mental health.

Note (2): TRCP treatment is defined in paragraph 1.4.1 and, generally speaking, is action taken by an education and research facility pursuant to an arrangement with the Commission to inquire into issues associated with the health of Defence Force members which could have a benefit for the health care of veterans and dependants of veterans, under the Act, and members and dependants of members or former members, under the MRCA.

Note (3): under s.88A(1)(d) of the Veterans’ Entitlements Act 1986 (VEA) a determination may be made granting eligibility for treatment under the VEA to “a person”. A determination has been made granting eligibility for TRCP treatment under the VEA to a member or former member under MRCA and to a dependant of a member or former member.

Note (4): prior approval for TRCP treatment is not required.

2.7B Australian Centre for Posttraumatic Mental Health Treatment

2.7B.1 The Commission may accept financial liability for ACPMH treatment provided for the benefit of an entitled veteran who is eligible for such treatment by virtue of Determination no.R32/2007 made under section 88A of the Act and entitled Veterans’ Entitlements Treatment (Australian Centre for Posttraumatic Mental Health) Determination 2007.

Note (1): under subsection 80(1) of the Act treatment can be action taken with a view to maintaining a person in physical or mental health.

Note (2): the intention is that the Commission may accept liability for ACPMH treatment even though such treatment is not directly provided by the Australian Centre for Posttraumatic Mental Health but under its auspices.

Note (3): The Treatment Principles establish the treatment called ACPMH treatment and the Determination entitled Veterans’ Entitlements Treatment (Australian Centre for Posttraumatic Mental Health) Determination 2007 (R32/2007), made under s.88A of the Act, establishes eligibility for that treatment.

Note (4): Unlike most of the eligibility provisions in Part V of the Act, eligibility for treatment under a “s.88A determination” need not relate to an injury or disease but can relate to a person’s condition generally.

Note (5): prior approval for ACPMH treatment is not required.

2.8 Loss of eligibility for treatment

2.8.1 Unless the Commission makes a determination under subsection 85(8) of the Act, it will not provide, arrange, or accept financial responsibility for treatment for a person, as an entitled person, on or from:

(a) the date of notification that the person is no longer eligible under section 85, 86, 88A or 88B of the Act; or

(b) the effective date of reduction or cancellation of the qualifying pension;

whichever is the later.

Note: Subsection 85(8) provides, in effect, that where a service pension is suspended, the Commission may determine that, for the purposes of treatment eligibility, the person is deemed to be continuing to receive that pension during the period, or part of the period, of suspension.

2.8.2 Where a person’s pension is reduced or cancelled because the person supplied false or misleading information, and that reduction or cancellation results in a reduction or loss of eligibility for treatment, treatment benefits will be reduced or will terminate from the date of reduction or cancellation of the pension.

PART 3 — COMMISSION APPROVAL FOR TREATMENT

3.1 Approval for treatment

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

Note: Paragraph 1.5.1 provides that any approval given for treatment under the Treatment Principles revoked upon the commencement of these Treatment Principles is deemed to have been given for the purposes of, and under, 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.

(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) convalescent care in an institution — except where the institution is a private hospital or public hospital;

Note: for convalescent care in an institution that is a hospital see paragraph 9.5.2

(ha) respite care in an institution — except where the institution is a private hospital or public hospital;

Note: for respite care in an institution where the institution is a hospital see paragraph 10.7A.

(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 or 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 overseas;

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 a visual aid to an entitled person by an optometrist or an optical dispenser that is either:

(i) not available to the entitled person under the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1; or

(ii) available to the entitled person under the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1, but with the stipulation that prior approval is required.

(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;

(c) the extent of funds that are available;

(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 a general practitioner 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 community nurse in accordance with paragraph 7.3.3 after the services have been provided;

Note:see principle 7.3.

(fa) treatment under the Veterans' Home Care Program except a service of emergency short term home relief (ESTHR) within 24 hours of a previous service of ESTHR;

Note:see principle 7.3A.

(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 an optical dispenser) provided that, if an optical product is dispensed, any requirement for prior approval in relation to that product imposed by 3.2.1(s) is satisfied.

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.

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

Note: (ka) convalescent care at a private hospital or public hospital;

Note: (kb) respite care in an institution — where the institution is a private hospital or public hospital.

(m) ambulance transport in an emergency or where that is the arrangement between ambulance service providers and the Commission;

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 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 for entitled persons and, subject to principle 2.2, for emergency treatment overseas for a war‑caused injury or disease 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 overseas 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”, referred to 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 (a Local Dental Officer)—the amount worked out under the DVA document titled “Fee Schedule of Dental Services for Dentists, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)”, referred to 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));

(ba) a dental hygienist, dental therapist or oral health therapist—the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dentists, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)”, referred to 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 hygienists, dental therapists and oral health therapists));

(c) a dental prosthetist  the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dental Prosthetists”, referred to 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the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dentists, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)”, referred to 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”, referred to 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”, referred to 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”, referred to 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 general practitioner  the amount worked out under the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services” referred to 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 General Practitioners;

General Practitioners Fee Schedule;

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

Kilometre Allowance;

Medication Review Fees;

Pathology Fee Schedule;

Ready Reckoner for General Practitioners;

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 General Practitioners ;.

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

the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services”, referred to 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 GPs;

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

Kilometre Allowance;

Medication Review Fees;

Pathology Fee Schedule;

Ready Reckoner for GPs

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”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects a neuropsychologist));

(ja) an occupational therapist  the amount worked out under the DVA document entitled “Occupational Therapists Schedule of Fees”, referred to 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”, referred to 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”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles , the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1, 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”, referred to 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 “Orthoptists Schedule of Fees”, referred to 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));

(ma) an orthotist  the amount worked out under the DVA document entitled “Orthotists Schedule of Fees” referred to 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(n) (Orthotists));

(n) an osteopath  the amount worked out under the DVA document entitled “Osteopaths Schedule of Fees”, referred to 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));

(oa) an outreach program counsellor — the amount worked out under the DVA document entitled “Veterans and Veterans Families Counselling Service (VVCS) Outreach Program Counsellor Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the VVCS OPC Provider Notes;

(p) a physiotherapist  the amount worked out under the DVA document entitled “Physiotherapists Schedule of Fees”, referred to 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”, referred to 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”, referred to 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”, referred to 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”, referred to 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”, referred to 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”, referred to 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

(c) if a claim for payment in respect of treatment:

(i) is in the form, if any, approved by the Commission for this purpose ('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 2 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.

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

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

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 2 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 Subject to paragraph 3.5.3A, the Commission will not accept financial responsibility for the cost of the following treatment by health care 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

(c) examination for employment purposes; or

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

3.5.3A Paragraph 3.5.3(a) does not apply to treatment that is private accommodation provided to an entitled person as a private patient in a hospital where a private health insurer of the person agrees to pay the difference between the cost of shared accommodation for the person at the hospital and the cost of the private accommodation for the person — the RPPPs covers such treatment.

Note 1: “private patient” is defined in s.90A(8) of the Act.

Note 2: this provision ensures paragraph 3.5.3(a) does not prohibit the Commission from accepting responsibility for part of the cost of private accommodation in a hospital where a private health insurer pays for the remainder of the cost.

The Commission’s responsibility in this area is regulated by the RPPPs i.e. cost‑sharing between the Commission and the entitled person or a private health insurer is worked out under the RPPPs.

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

3.1 Approval for treatment

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

Note: Paragraph 1.5.1 provides that any approval given for treatment under the Treatment Principles revoked upon the commencement of these Treatment Principles is deemed to have been given for the purposes of, and under, 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.

(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) convalescent care in an institution — except where the institution is a private hospital or public hospital;

Note: for convalescent care in an institution that is a hospital see paragraph 9.5.2

(ha) respite care in an institution — except where the institution is a private hospital or public hospital;

Note: for respite care in an institution where the institution is a hospital see paragraph 10.7A.

(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 or 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 overseas;

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 a visual aid to an entitled person by an optometrist or an optical dispenser that is either:

(i) not available to the entitled person under the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1; or

(ii) available to the entitled person under the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1, but with the stipulation that prior approval is required.

(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;

(c) the extent of funds that are available;

(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 a general practitioner 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 community nurse in accordance with paragraph 7.3.3 after the services have been provided;

Note:see principle 7.3.

(fa) treatment under the Veterans' Home Care Program except a service of emergency short term home relief (ESTHR) within 24 hours of a previous service of ESTHR;

Note:see principle 7.3A.

(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 an optical dispenser) provided that, if an optical product is dispensed, any requirement for prior approval in relation to that product imposed by 3.2.1(s) is satisfied.

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.

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

Note: (ka) convalescent care at a private hospital or public hospital;

Note: (kb) respite care in an institution — where the institution is a private hospital or public hospital.

(m) ambulance transport in an emergency or where that is the arrangement between ambulance service providers and the Commission;

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 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 for entitled persons and, subject to principle 2.2, for emergency treatment overseas for a war‑caused injury or disease 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 overseas 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”, referred to 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 (a Local Dental Officer)—the amount worked out under the DVA document titled “Fee Schedule of Dental Services for Dentists, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)”, referred to 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));

(ba) a dental hygienist, dental therapist or oral health therapist—the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dentists, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)”, referred to 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 hygienists, dental therapists and oral health therapists));

(c) a dental prosthetist  the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dental Prosthetists”, referred to 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the amount worked out under the DVA document entitled “Fee Schedule of Dental Services for Dentists, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)”, referred to 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”, referred to 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”, referred to 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”, referred to 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 general practitioner  the amount worked out under the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services” referred to 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 General Practitioners;

General Practitioners Fee Schedule;

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

Kilometre Allowance;

Medication Review Fees;

Pathology Fee Schedule;

Ready Reckoner for General Practitioners;

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 General Practitioners ;.

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

the DVA document entitled “Department of Veterans’ Affairs Fee Schedules for Medical Services”, referred to 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 GPs;

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

Kilometre Allowance;

Medication Review Fees;

Pathology Fee Schedule;

Ready Reckoner for GPs

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”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and Notes for Allied Health Providers (Section 1 General Information and Section 2(a)(as section 2(a) affects a neuropsychologist));

(ja) an occupational therapist  the amount worked out under the DVA document entitled “Occupational Therapists Schedule of Fees”, referred to 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”, referred to 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”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles , the DVA document entitled “Pricing Schedule for Visual Aids”, referred to in Schedule 1, 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”, referred to 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 “Orthoptists Schedule of Fees”, referred to 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));

(ma) an orthotist  the amount worked out under the DVA document entitled “Orthotists Schedule of Fees” referred to 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(n) (Orthotists));

(n) an osteopath  the amount worked out under the DVA document entitled “Osteopaths Schedule of Fees”, referred to 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));

(oa) an outreach program counsellor — the amount worked out under the DVA document entitled “Veterans and Veterans Families Counselling Service (VVCS) Outreach Program Counsellor Schedule of Fees”, referred to in Schedule 1, on condition that the treatment was provided in accordance with the Principles and the VVCS OPC Provider Notes;

(p) a physiotherapist  the amount worked out under the DVA document entitled “Physiotherapists Schedule of Fees”, referred to 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”, referred to 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”, referred to 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”, referred to 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”, referred to 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”, referred to 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”, referred to 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

(c) if a claim for payment in respect of treatment:

(i) is in the form, if any, approved by the Commission for this purpose ('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 2 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.

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

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

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 2 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 Subject to paragraph 3.5.3A, the Commission will not accept financial responsibility for the cost of the following treatment by health care 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

(c) examination for employment purposes; or

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

3.5.3A Paragraph 3.5.3(a) does not apply to treatment that is private accommodation provided to an entitled person as a private patient in a hospital where a private health insurer of the person agrees to pay the difference between the cost of shared accommodation for the person at the hospital and the cost of the private accommodation for the person — the RPPPs covers such treatment.

Note 1: “private patient” is defined in s.90A(8) of the Act.

Note 2: this provision ensures paragraph 3.5.3(a) does not prohibit the Commission from accepting responsibility for part of the cost of private accommodation in a hospital where a private health insurer pays for the remainder of the cost.

The Commission’s responsibility in this area is regulated by the RPPPs i.e. cost‑sharing between the Commission and the entitled person or a private health insurer is worked out under the RPPPs.

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

PART 4 — MEDICAL PRACTITIONER SERVICES

4.1 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.

To achieve this objective the Commission or the Department deals with medical practitioners on two levels.

At the first level the Commission or the Department deals with medical practitioners called general practitioners. Services provided by these medical practitioners must be in accordance with these Principles and the Notes for General Practitioners if the Department is to pay for the services.

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 second level of interaction between the Commission or the Department and medical practitioners is where the medical practitioner is a specialist.

Unlike general practitioners, medical specialists (as at 1 April 2006) are not prepared to submit to the same level of regulation as general practitioners 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 a general practitioner or a medical specialist.

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 general practitioner; 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 or the Department of Veterans’ Affairs Fee Schedules for Medical Services (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 general practitioner; 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.

4.2.8 DVA Fee Schedule Services

4.2.9 Despite paragraph 4.2.1, an entitled person may be provided with services included in the Department of Veterans’ Affairs Fee Schedules for Medical Services.

4.2.10 Services provided under paragraph 4.2.9 may be provided only by a general practitioner or a medical specialist.

4.2.11 Prior approval is not required for services provided under paragraph 4.2.9.

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 where a general practitioner or specialist provides or arranges for treatment of:

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

(b) a veteran who has been issued with a White Card for any war‑caused or other specifically listed injury or disease or for a determined condition; or

(c) a person who has been issued with a written authorisation on behalf of the Commission;

but the Commission will not accept financial responsibility for treatment costs where a general practitioner or specialist provides or arranges for treatment of a "determined residential care condition".

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 general practitioner or specialist shall bill only:

(a) the Department; or

(b) the Commission; or

(c) the Department of Human Services,

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 general practitioner 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 general practitioner 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 general practitioner or medical specialist had provided the service as a practitioner under that Act.

4.4 Referrals

4.4.1 A general practitioner may refer an entitled person for:

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

(b) treatment from a general practitioner 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

(c) treatment in a hospital or other institution as indicated in these Principles; or

(d) other health‑care services 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, 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 general practitioner;or

(c) arrange treatment in a hospital or other institution as indicated in these Principles; 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 general practitioner.

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 2004, prior approval is required for the referral of entitled persons to medical specialists.

4.7.2 Prior approval is required for:

(a) the provision of psychotherapy treatment to entitled persons; or

(b) the provision of services under paragraph 4.2.3.

4.7.3 Prior approval is not required when a general practitioner 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 general practitioner’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

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

(c) examination for a medical certificate for membership of a friendly society; 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

(k) vaccination for an entitled person who proposes to travel outside Australia, unless:

(i) the person is the holder of a Gold Card; and

(ii) the person is in Australia at the time the vaccination is provided; and

(iii) the vaccination is provided to the person under the Repatriation Pharmaceutical Benefits Scheme.

Note 1: a vaccination is not treatment of an injury or disease. It is preventive treatment. Normally an entitled person under the Act is only eligible for treatment of an injury or disease. Eligibility for preventive treatment such as a vaccination is granted by a determination under s.88A of the Act – in this case the Veterans’ Entitlements (Vaccinations for Overseas Travel) Eligibility Determination 2010.

Note 2: an approved medical practitioner is also a Community Pharmacist under the Repatriation Pharmaceutical Benefits Scheme.

5.1 Providers of services

The Commission may accept financial responsibility for dental treatment provided to an entitled person by a dental prosthetist, dentist, dental specialist, dental hygienist, dental therapist or oral health therapist where the treatment is provided in accordance with:

(a) these Principles; and

(b) the Notes for Allied Health Providers (Section 1 General Information and Section 2(c) (as Section 2(c) affects dental prosthetists, dentists, dental specialists, dental hygienists, dental therapists and oral health therapists, 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, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)” or the “Fee Schedule of Dental Services for Dental Prosthetists” provides that prior approval is not required for the treatment.

Note: paragraph 5.4.1 deals with emergency dental treatment.

5.1.3 Subject to prior approval, an entitled person may be referred to a dental specialist by a dental hygienist, dental therapist, oral health therapist, dental prosthetist, dentist or other dental specialist.

5.2 Financial responsibility

The DVA Document entitled “Fee Schedule for Dentists, Dental Specialists and other Dental Practitioners (excluding Dental Prosthetists)”, referred to in Schedule 1, and comprised of Dental Schedules A, B and C, lists the dental services provided by dentists, dental specialists, dental hygienists, dental therapists or oral health therapists, 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”, referred to in Schedule 1, lists the dental services 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 (biennial monetary limit) in respect of dental services provided to an entitled person under that Schedule in a period of two consecutive Calendar years.

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.

5.2.5 The biennial monetary limit set under Dental Schedule C in 5.2.1 will not apply in relation to a dental service where that service is for:

(a) a war‑caused injury or disease or a determined condition except a determined residential care condition of an entitled person receiving residential care; or

(b) a condition associated with malignant neoplasia; or

(c) a former prisoner of war.

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, dental specialist, dental hygienist, dental therapist or oral health therapist had provided the service as a practitioner under that Act.