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No. 15 MRCA Treatment Paths

MILITARY REHABILIATION AND COMPENSATION ACT 2004 (MRCA) POLICY INSTRUCTION – NUMBER 15

Subject: MRCA Treatment Paths

Purpose

The purpose of this instruction is to assist delegates in making a decision under section 327 of the Military Rehabilitation and Compensation Act 2004 (MRCA). This advice seeks to clarify the policy surrounding the application of either section 271 or 280 of the MRCA – specifically whether a claimant should have their reasonable treatment costs reimbursed under s.271 (Treatment Pathway 1) or be issued with a White Card under s.280 of the MRCA (Treatment Pathway 2).

Background

The treatment provisions in the MRCA reflect a combination of those found in the Safety Rehabilitation and Compensation Act 1988 (SRCA) and the Veterans' Entitlements Act 1986 (VEA).

The SRCA type provisions allow for the payment/reimbursement of reasonable costs incurred in the treatment of an injury or disease, for which liability has been accepted.

The card treatment provisions in the MRCA, which are based on the VEA arrangements, allow for treatment as provided for in the MRCA Treatment Principles.

Once a person claims compensation, the delegate must carry out a needs assessment under section 325 of the MRCA, and then must determine, under section 327, whether the claimant should have their treatment costs reimbursed (Treatment Pathway 1) or whether they should be issued with a White Card (Treatment Pathway 2).

What is provided for in the MRCA?

The MRCA provides two pathways for treatment for former members of the ADF, compensation for the cost of reasonable medical treatment similar to that provided under the SRCA, or the provision of a Health Care Card similar to that provided under the VEA.  MRCA delegates are required to decide which pathway is most appropriate following an assessment of a client's needs pursuant to section 325 of the MRCA.

Sections 272 and 279 allow for the provision of treatment under the MRCA for serving Australian Defence Force (ADF) personnel, where the Military Rehabilitation and Compensation Commission (MRCC) determines, on advice from the member's  service chief that it is appropriate to do so.  This is expected to occur in transition to medical discharge.  In all other cases, serving members are provided with treatment for injuries or diseases under the Defence Regulations.

Previous advice

Policy Instruction 11 – Treatment Paths

Delegates should note the advice contained in Policy Instruction (PI) Number 11. PI 11 clarifies the treatment entitlement of persons with 60 or more impairment points and the import of section 281 of the Military Rehabilitation and Compensation Act 2004 (MRCA).

The issue of the Gold Card is automatic upon that permanent impairment decision being recorded in CADET.  However, a decision as to whether a MRCA client is entitled to reimbursement for reasonable medical treatment under Treatment Pathway 1 or a White card under Treatment Pathway 2, remains a discretionary decision for MRCA delegates to consider.

When issued with a MRCA treatment card, holders become entitled to treatment provided through  the MRCA Treatment Principles (contained in Instrument No. M21 of 2004), Private Patient Principles (contained in Instrument No M17 of 2004) and Pharmaceutical Benefits Scheme (contained in Instrument No M22 of 2004).  These instruments are available in the CLIK reference library under the Legislation heading.  The scope of the treatment provided through a MRCA treatment card replicates what is available to veterans under the repatriation card system.

Businessline - Residential care for MRCA treatment card holders

Delegates should also note the content of the Businessline dated 22 August 2006 in relation to Residential Care for MRCA treatment card holders.  This Businessline provides guidance on circumstances where the National Manager Compensation Policy may approve the total residential care costs over and above what would normally be provided for in Part 10 of the MRCA Treatment Principles.

Issues arising?

There has been a number of reports of perceived  shortcomings in treatment that is available to a MRCA client with a White Card, when compared to what might previously have been considered reasonable medical treatment under Treatment Pathway 1 - reimbursement.

Some of these issues which have been raised include:

  • A medical provider refusing to accept the White Card;
  • Over the counter medications not being provided for; and
  • A gym program being rarely approved under the White Card Pathway.

As a result of these issues, clarification has been requested as to the point at which clients should be transferred from Treatment Pathway 1 to Treatment Pathway 2, with the consequent issue of a White card.

Issues to consider before making a treatment path decision
Existing Treatment Providers

Prior to making a decision that a client should receive a White Card, delegates should check if existing treatment providers will accept the White Card and continue to treat the claimant on that basis.  Similarly delegates should check whether the nature of any ongoing treatment is likely to be covered under a White Card.  If these two conditions are not met then it may be inappropriate to change treatment pathways, until the current period of treatment has concluded.

Rehabilitation Program

Delegates may also consider the nature of any treatment modality and consider whether this would more appropriately be provided in conjunction with a rehabilitation program provided in accordance with Chapter 3 of the MRCA, as a once-off rehabilitative measure.  For example, a gym program will rarely be approved under the White Card system, and then generally only in conjunction with a physiotherapy treatment program.  However, if there is an assessed need and the client is already participating in a rehabilitation program, then the merits of the gym program could be considered as part of that rehabilitation program.  Please note that as a general rule medical treatment should not be provided under Chapter 3.

Issues to consider - Treatment under MRCA for serving members of the ADF transitioning to civilian life

Delegates, in conjunction with a client's discharge from the ADF, should consider when is the most appropriate time to issue a White Card?

For example, frequently full time serving members relocate at the time of their discharge from the ADF.  This may present an ideal opportunity for the person, who is already locating new treatment providers post discharge, to select providers who will accept the White Card.

Prior to making a decision that a client should receive a White Card, delegates should check if existing treatment providers will accept the White Card and continue to treat the claimant on that basis.  Delegates may also consider checking whether the nature of any ongoing treatment is likely to be covered under a White Card.  If these two conditions are not met, it may be inappropriate to change treatment pathways until the current period of treatment has concluded.

Issues to consider - Treatment under MRCA for serving members of the ADF being medically discharged

In the case of medical discharge, the Transition Management Service (TMS) should ascertain what treatment and which treating providers will be relevant immediately post-discharge.

This information should be used during the Needs Assessment and inform any decision on treatment path.

What happens when treatment required is not covered by the MRCA Treatment Principles?

Where the treatment card holder requires treatment that is not obviously available through the MRCA Treatment Principles, the delegate should ascertain whether or not the item can be provided via the Rehabilitation Aids and Appliances (RAP) program or a prior approval from a Health Services delegate.  Some examples of these circumstances may include prescription medication and continence aids for paraplegics.

Delegates should be aware that the Health Care Card system will not automatically provide for all treatment modalities, however exceptions can be made in special circumstances.  In these cases, the treatment provider should submit their justification for a particular treatment (in writing) for prior approval from a Departmental Health delegate.  Similarly only medications listed on the Pharmaceutical Benefits Scheme or additional medications and dressings listed on the Repatriation Schedule will be provided via the Health Care Card system.  Again, treating providers may seek prior approval from a Departmental Health delegate if they consider that special circumstances exist.

How do you transfer a client from Treatment Pathway 2 to Treatment Pathway 1?

Where the client already has a white card, it is open to the MRCA delegate to change the Treatment Pathway back to Treatment Pathway 1.  In order to do this, the delegate must conduct a needs assessment in accordance with section 325 of the MRCA, and make a determination under section 327 that the claimant is entitled to reasonable medical treatment under section 271, as distinct from a White Card under section 280.  This action should only be taken after all other avenues have been explored as indicated above.

What happens when both SRCA and MRCA eligibility exist?

Subsection 15(3) of the Military Rehabilitation and Compensation (Consequential and Transitional Provisions) Act 2004 (CATP) provides that a client who would be entitled to the same treatment under both ss16(1) of the SRCA and part 2 of Chapter 6 of MRCA, is only entitled to receive that treatment under the MRCA provisions.  This provision is particularly relevant where a client has a condition accepted under SRCA, with that same condition aggravated during MRCA service.

Further Investigation

Subsection 287(2) of MRCA makes provision for the approval of treatment that might not normally be approved within the Health Care Card system.  Advice is still being sought on the use of this provision, and further advice will be issued at a later date.  Delegates should not use this provision until further advice is issued.

Delegates are requested to advise any problems with obtaining treatment utilising the MRCA White Card, when the same treatment would have been considered reasonable under Pathway 1, on the transitional issues discussion line.

Contact

Any queries concerning this instruction should be addressed to Brenda Franklin on extension 16426 or Mark Tonkin on extension 50391.

Michelle Glanville

A/g National Manager

Compensation Policy

      September 2006