B29/1992 PHARMACEUTICAL ALLOWANCE : PROCESSING "PA ONLY" CASES VIA PIPS.

DATE OF ISSUE: 28 JUNE 1992

PHARMACEUTICAL ALLOWANCE : PROCESSING "PA ONLY" CASES VIA PIPS.

CONTENTS

TopicParagraph

Purpose of DI — 2

Background — 3-4

Processing guidelines — 5-9

Treatment entitlement under VEA S85 — 10-11

Recording of Treatment eligibility — 12-14

Cross Reference cases — 15

Advances and automatic suspensions — 16

Method of Assessment 04 cases — 17

Keyfast access — 18

Payment Advices — 19

Eligibility recorded prior to 24 Feb 1992 — 20-21

Tax File Numbers — 22

Screens accessed to process PA only cases — Appendix A

Choice of receiving PA from DVA or DSS — 24-27

AMS, Rule B and DP dependants pensions — 28

Overseas Disability pensions — 29

Veterans living overseas — 30

Introduction

In this instruction, clients who are eligible for Pharmaceutical Allowance (PA) but not in receipt of any other DVA payments are referred to as "PA only" cases.  A person becomes eligible for PA only when he/she is first given approval for treatment at Departmental expense, ie.

- either through acceptance of  disabilities which do not warrant payment of a pension at any rate; or

- through section 85(2) & 85(4) of the VEA (WW1, female veteran WW2, cancer, POW).

Purpose

2.The principal purpose of this instruction is to formalise guide-lines for processing PA only grants for clients who do not receive other DVA payments.

Background

3.When PA was extended to pensioners eligible for pharmaceuticals under the Repatriation Pharmaceutical Benefits Scheme (RPBS), a manual coding sheet was required to put PA only payees onto the Payment Master File.

4. Enhancements were made to the Pensions Information Processing System (PIPS) and related systems from 23 February 1992,  to enable a CDB and PMF record to be created on-line via PIPS instead of using manual coding sheets. This means that new grants of PA only must be  processed through PIPS.

Processing guide-lines

5.When the EATERS system is updated to reflect a person first becoming eligible for treatment, via the Record Decision (RD) facility, the ADP system will automatically generate a DP grant case (classification 334) on CMS and PIPS.

The DP grant case may be used to process the grant of PA in the same way that a new disability pension grant would be processed on PIPS, ie. from Assessment Control (AC) stage through to Determination (DE) stage.  A DP grant case is only generated if the client has no existing payments (including PA).

6.If a client becomes eligible for PA only, Benefits Program staff have the responsibility of putting PA into payment.

7.If the client has existing DP or SP payments, then PA will already be in payment.

8.If the action which generated treatment eligibility is also generating a grant of DP at a rate greater than zero, then PA will be granted automatically as part of the DP grant.

9.Any DP grant case created on or after 24 February has an attribute automatically set. There are three attributes which deal with PA :

. Disab Pension grant (055)for veterans first becoming eligible for               payment of  disability pension;

. PA only (DISAB) grant (065)for veterans having a disability accepted               for the first time but at a non pensionable               rate;

. PA only (TMT) grant (075)for veterans having treatment                eligibility granted for the first time.

Treatment entitlement under sections 85(2) & 85(4) of the VEA

10.The source of eligibility which lies outside the Benefits Program's control is  acceptance of treatment entitlement under sections 85(2) and 85(4) of the VEA. S85(2) deals with treatment for malignant neoplasia and tuberculosis; section 85(4) deals with treatment for any condition for WW1 veterans, certain female veterans, prisoners of war and civilian detainees of the enemy. Since these cases need not have lodged a pension claim, it it is necessary for Benefits Program staff to be made aware of new cases of this sort where no other pension is in payment.

11.Each Branch Office should have established a local mechanism by which cases which become entitled to treatment (but are not entitled to pension) can be reported upon. The Claims Management System (CMS) reporting facilities can be used to set up periodic reports (eg daily, weekly, fortnightly, monthly) which list all cases with attribute number 075, thereby ensuring that these treatment-only cases are reported on, and can be investigated for possible PA grant action.

Recording of treatment eligibility

12.Staff recording treatment eligibility should use the appropriate classification item - e.g., Tmt Malig Neoplasia,,Tmt Detainee, Tmt First War, etc on the CMS Classify Entitlement (CM.CE) screen.

13.To record TSW entitlement, the classification type Entitlement Decision Amend or Treatment Decision Amend must be used to ensure a case is automatically generated for PA payment.  This is because there is no specific classification for the treatment eligibility type of Treatment Second War (TSW) on the CMS Classify Entitlement facility.

14.It is important to note that no CMS DP grant case will be generated if Historic Data Collection (HDC) is used; ie. those staff responsible for granting the payment of PA will be unaware of the case if HDC has been used; it is therefore important that the Decision Amend type be used.

Cross reference cases

15.Some dual payments of PA have been identified with clients who receive payments or have eligibility under two different file numbers. Proper cross-referencing will resolve some of these, and wherever possible such clients should receive all their payments on the one file number.

Advances and automatic suspensions

16.For PA only cases, when an advance payment of PA is made, the system automatically generates a suspension segment (code 7240) on the PMF. This action appears on the report of PMF transactions.  At the end of the advance payment period, the system will automatically remove the suspension segment thereby restoring fortnightly PA payments. It is important to note that this will occur only when PA is the sole payment on the system.

Method of Assessment (MOA) 04 cases

17.In a married SP case where the veteran only receives service pension and the spouse receives neither SP nor DSS pension, there may be a few cases where the non-pensioner spouse is a war widow, or receives DP in their own right, or has treatment eligibility and therefore has entitlement to PA.  In those cases, the spouse is entitled to $5.20 PA, but the veteran service pensioner still receives PA of $5.20 per fortnight (rather than the partnered rate of $2.60). It is not anticipated that this will be changed, given the small numbers involved.

Keyfast Access

18.The Keyfast facility previously used to grant or cancel PA through a manual coding sheet will remain available for a time, solely to allow Systems Support staff to resolve any unusual system problems.

Pension Payment Advices

19.The daily pension payment advices produced for payment variations now are produced for grants of PA only cases. The form of the advice is almost identical to that produced for DP grants (where there is no SP in payment), with the exception that the paragraph about non-taxability is deleted.

Eligibility recorded prior to 24 Feb 1992

20.The following cases will not have an action created automatically on CMS to generate a PA payment:

.Clients who became eligible for treatment in the past few months, and prior to 24 February 1992,  but who have not as yet been put into payment for PA. (A list of these cases was sent to Branches in January 1992, and a final list for any subsequent cases granted up to 23 February 1992 has been despatched recently); and

.Clients who were already eligible for treatment but who belatedly return the PA data collection form sent to them last year.

21.These cases should be registered under the "Classify Pension" screen of CMS.  The classification to be used is "DP Data Change" (item 02).

Tax file numbers

22.The Tax File Number (TFN) legislation does not apply to PA.  There is no proposed change to this policy. The PIPS submission program will not permit a case to be submitted until the TFN exemption is recorded.  Therefore, a TFN exemption needs to be recorded as part of the processing. The reason to be recorded on the TN.AE screen is "not covered by legislation".

Screens which are accessed for PA only cases

23.Appendix A summarises the screens which are accessed  for PA only grants.

Choice of whether or not to receive PA from DVA

24.When a veteran becomes eligible for PA only through treatment eligibility, it is not necessarily the case that DVA must grant Pharmaceutical Allowance.  The veteran may not wish to receive the allowance, or may already be receiving it from Social Security. When sending a PA Payment Form to the Veteran, the covering letter should be worded so as to let the veteran know that if s/he is already receiving PA from DSS then it is not necessary to return the form.

25.In cases where PA is not to be granted, the CMS/PIPS case created by the system should be finalised by withdrawal, so that it ceases to appear as an outstanding action.

26.In cases where the veteran is a member of a couple, and both members of the couple receive a pension and PA from DSS, a DVA grant of PA to the veteran will result in cancellation of the couple's PA from DSS.  DVA cannot "split" the allowance between the veteran and spouse, and  some spouses may feel disadvantaged by this arrangement. Pensioners receiving PA only from DVA may elect to resume receipt of PA from DSS in lieu, if they wish.

27.The option of receiving PA from DSS is possible only for those not receiving any Disability Pension from DVA. Veterans who receive DP from DVA and a pension from DSS cannot choose which Department pays their PA, since the two Departments' ADP systems have been set up such that DVA must pay PA to recipients of DP.

AMS/Rule B/DP dependants

28.Clients who receive an AMS pension, frozen Rule B service pension, or a DP dependants pension are not eligible for PA from DVA.  Recipients of these

payments (provided they have no other DVA eligibility) should be receiving PA from the Department of Social Security, if they are in receipt of a DSS pension.

Overseas Disability Pensions

29.BPOD Veterans are entitled to PA, since they have RPBS eligibility - that is, they have treatment cards (STEC) issued to them. BPOD War Widows are NOT entitled to PA in their own right, as they have no RPBS eligibility.

Veterans living overseas

30.Clients do not automatically lose eligibility for PA if they reside or travel overseas. This differs from Social Security's practice, whereby eligibility is lost even during short overseas absences.

31.BPOD veterans (with no other eligibility) normally have their STEC card recalled upon returning overseas permanently; the question of whether such veterans are entitled to continue receiving PA is being examined, and a memorandum will be issued on this matter as soon as it is resolved.

Kay Grimsley

Assistant Secretary income support

Benefits program

June 1992
Appendix A

Steps for recording treatment  eligibility on CMS/EATERS

so as to generate a case for PA payment.

CM.CESelect item 16-19 or item 05  as appropriate.

(Note: use of item 01 will NOT produce a case for granting PA)

EN.OTEnter treatment eligibility details

EN.DCPrint data collection summary

EN.RDDelegate records the decision

Steps for granting Pharmaceutical Allowance on PIPS

following the generation of a DP grant case by the EATERS Record Decision (EN.RD) facility; OR

after registering a DP Data Change case via the CMS Classify Pension (CM.CP) facility.

PP.ACCreate Action Assessment

PP.PYEnter Payment details

PP.ADEnter Advice details

PP.AREnter arrears if applicable

TN.AERecord TFN exemption reason

("Not covered by legislation")

PP.SUSubmit case

PP.DEDetermine case