Defence Determination 2014/49, National ADF Family Health Program

Defence Determination 2014/49, National ADF Family Health Program

I, CHRISTON SCOTT CHAMLEY, Acting Director General People Policy and Employment Conditions, make this Determination under section 58B of the Defence Act 1903.
Dated 1 October 2014
C S CHAMLEY
Acting Director General
People Policy and Employment Conditions
Defence People Group

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Citation

1. / This Determination is Defence Determination 2014/49, National ADF Family Health Program.
2. / This Determination may also be cited as Defence Determination 2014/49.

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Commencement

This Determination is taken to have commenced on1 January 2014.

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Amendment

Defence Determination 2005/15, Conditions of Service, as amended,1 is amended as set out in this Determination.

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Clause 8.0.2 (Contents)

after Part 7A, insert
Part 8 / National ADF Family Health Program

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Chapter 8 Part 7A (Family assistance for attendance at a coronial inquest)

after Part 7A, insert
the Part in the schedule

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Transitional

1. / This clause applies in relation to a personifall of the following circumstances are met.
a. / The person was recognised asa dependantof a member in accordance with Chapter1 Part 3 Division 2of Defence Determination 2005/15, Conditions of service, for the whole or any part of the period between 1January2014 and the commencement of this Determination.
b. / The person incurred health care costs of a typethat would have been reimbursable under this Determination if it had commenced on 1 January 2014.
c. / The person was a Defencerecognised dependant of a member of the Permanent Force or a member of a Reserve Force on continuous full time service at the time the health cost was incurred.
d. / There are payment receipts, and where applicable private health insurance receipts, for the health care costs referred to in paragraph b.
e. / The dependant has been registered for the National ADF Family Health Program.
2. / The ADF member, their dependant or a relevant legal personal representative may be reimbursed for the health care costs, up to the amount that would have been reimbursable to the member's family under this Determination if it had commenced on 1 January 2014.
3. / Claims under this transitional provision must be made within 12 months of incurring the health care cost.
NOTE
1. / Defence Determination 2005/15, as amended to date. For previous amendments see Note
to Defence Determination 2014/1 and amendments made by Defence Determinations
2014/1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28,
29, 30, 31, 32, 33, 34, 35, 36, 38, 39, 40, 41, 42, 43, 44, 45, 47 and 48.

SCHEDULE

Part 8: National ADF Family Health Program

8.8.1Purpose

The purpose of this Part is to reimburse ADFmembersor eligible dependants for health costs incurredwithin Australia by a dependant registeredunder the National ADF Family Health Program.

8.8.2Members this Part applies to

1. / This Part applies to the following memberswith one or more eligible dependants.
a. / Permanent Forces members.
b. / Reserve members on continuous full-time service.
2. / This Part does not apply in relation to health costs incurred by a member or their dependant in any period in which the member is serving as a member of a Reserve Force and is not on continuous full-time service.

8.8.3Definitions

This table defines terms used in this Part.
Term / Meaning in this Part
Claimant / Means a person eligible to receive reimbursement under the program.
Note: This is not necessarily the person who pays for the service or product.
The claimant is any one of the following.
a. / The member.
b. / The member's eligible dependant.
c. / The legal personal representative of either or both the member or an eligible dependant.
Eligible dependant / Means a member's dependant,for whom all of the following conditions are met.
a. / The dependant is recognised as a dependant in accordance with Chapter 1 Part 3 Division 2.
See: Chapter 1 Part 3 Division 2, Definitions – dependants
b. / The dependant is listed on the Defence Personnel Management Key Solution System (called PMKeyS).
c. / The dependant is registered for The Program.
General practitioner / Means a person who meets the definition of a general practitioner under section 3 of the Health Insurance Act 1973.
See:
Health Insurance Act 1973
Term / Meaning in this Part
Medicare Benefits Schedule / Means the list of rebateable items made under the Health Insurance Act 1973.
Out of pocket expenses / Means the difference between the amount that is charged for an item provided to an eligible dependant and the amount of Medicare rebate that may be paid for that item.
Specialist / Means person who meets the definition of a specialist under section 3 of the Health Insurance Act 1973.
See:Health Insurance Act 1973
Specialist services / Means services provided by a specialist that are provided in consulting rooms, or in a hospital or institutional setting.
The Program / Means the National ADF Family Health Program.

8.8.4General practice settingbenefits

1. / A claimant may be reimbursed for all out of pocket expenses incurred by an eligible dependant for medical services provided in a general practice setting.
2. / A service referred to in subclause 1must have a Medicare Benefits Schedule item number. It does not need to be provided by a general practitioner.
Example:A nurse practitioner provides the service at the general practice and the out of pocket expenses for it are claimed under The Program.
3. / Despite the limit in subclause 2, if a service could reasonably be expected to attract a Medicare rebate but for the fact that the patient is not eligible for Medicare, the claimant can be reimbursed the full amount of the fee that the general practice charged for that item.

8.8.5Specialists and alliedhealth benefits

1. / The maximum that may be reimbursed to a claimant under this clause for any financial year from 1 July 2015 is $400 for each of a member's eligible dependants.
2. / For the period 1January2014 to 30June2014, a half-year reimbursement maximum of $200 per eligible dependant applies.
3. / Reimbursement under this clause is limited to the out of pocket expenses incurred by an eligible dependant, for services or products described in paragraphs a, b and c of this subclause, and excluding costs described in subclause 4.
a. / Consultation with a specialist.The service must have a Medicare Benefits Schedule Item Number.
b. / Medically prescribed, dental and optical appliances.
c. / An allied health service, including any listed in the following table.
Item / Service / Benefit
1. / Audiology / Consultation by an eligible audiologist under the Health Insurance (Allied Health Services) Determination 2014.
See:Health Insurance (Allied Health Services) Determination 2014
2. / Chiropracticand Osteopathy / Consultation by a chiropractor or osteopath registered with the Australian Health Practitioner Regulation Agency.
See: Australian Health Practitioner Regulation Agency website for registered practitioners
3. / Dental / Consultation by a dentist registered with the Australian Health Practitioner Regulation Agency. Includes items listed by the Australian Dental Association (ADA).
See:
1. Australian Health Practitioner Regulation Agency website for registered practitioners
2. The Australian Schedule of Dental Services and Glossary for included items
4. / Dietary / Consultation by an allied health professional under the Health Insurance (Allied Health Services) Determination 2014.
See:Health Insurance (Allied Health Services) Determination 2014
5. / Occupational Therapy / Consultation by an occupational therapist registered with the Australian Health Practitioner Regulation Agency.
See:Australian Health Practitioner Regulation Agency website for registered practitioners
6. / Optical / Consultation by an optometrist registered with the Australian Health Practitioner Regulation Agency. Includes all prescription eyewear, lenses, frames, contact lenses and repairs.
See: Australian Health Practitioner Regulation Agency website for registered practitioners
7. / Physiotherapy / Consultation by a physiotherapist registered with the Australian Health Practitioner Regulation Agency.
See: Australian Health Practitioner Regulation Agency website for registered practitioners
8. / Podiatry and Chiropody / Consultation by a podiatrist or chiropodist registered with the Australian Health Practitioner Regulation Agency.
See: Australian Health Practitioner Regulation Agency website for registered practitioners
Item / Service / Benefit
9. / Psychology / Consultation by a psychologist registered with the Australian Health Practitioner Regulation Agency.
See: Australian Health Practitioner Regulation Agency website for registered practitioners
10. / Speech Therapy / Consultation by an allied health professional under the Health Insurance (Allied Health Services) Determination 2014.
See:Health Insurance (Allied Health Services) Determination 2014
4. / Specialist and allied health services to which either or both the following descriptions apply are not reimbursed under The Program.
a. / They attract goods and services tax (GST).
b. / They are cosmetic.
5. / The benefit may be transferred to other eligible dependants of the member.
Example:A family of three has registered for The Program and has been allocated a total of $1,200 for the financial year (i.e. $400 maximum per dependant). One of the dependants undergoes extensive physiotherapy. The dependant’s annual $400 allocation has been claimed but there is still an amount outstanding. The claimant is able to use part or all of the other dependants’ allocation to cover out of pocket expenses, with the understanding that another allocation is not available until the next financial year.
6. / Claimants may be reimbursed for out of pocket expenses under The Program for eligible dependants withprivate health insurance. The following conditions apply.
a. / Any private health rebate must be claimed before claiming reimbursement under The Program.
b. / The claimant may only be reimbursed the cost of the service, less any Medicare and private health insurance rebates, up to their remaining yearly limit.
c. / The claimant must provide any relevant private health insurance receipts with their claim.
7. / The claimant must provide payment receipts with their claim, in order to be reimbursed under The Program.
8. / In addition to the requirements of subclauses 6 and 7, a claimant who seeks reimbursement for a medically prescribed appliance must include a copy of the recommendation or prescription for the item from a registered practitioner.

8.8.6Hospital and institutional expenses are not reimbursed

Costs incurred for admissions, stays and accommodation in hospitals or institutional settings are not reimbursed under The Program.

8.8.7Registering for The Program

1. / To register a dependant for the purposes of The Program, a member must takeall of the following actions.
a. / Ensure the dependant is listed and their details up-to-date in the Dependant/Beneficiary section ofDefence’s Personnel Management Key Solutions system (PMKeyS). To list or update dependant details the member must useform AD160 – ADF Dependant Details.
See: Webform AD160 – ADF Dependant Details
b. / Register for The Program using form AD858-1, ADF Family Health.
See:Webform AD858-1, ADF Family Health
Notes:
1. The member will be sent an ADF Family Health Card after dependants have been successfully registered.This card can be used to pay for services at the point of sale where the provider has software installed to enable that.
2. Because a dependant does not become eligible until after they have been registered on The Program, claims cannot be made for services that are provided on a day before the dependant is registered.
2. / Eligible dependants can only be registered by one ADF member. If an eligible dependant has more than one parent or guardian who could register them under The Program, then only one of those members may register the dependant.
Note: It is for the members to decide and agree which one of them performs that task.
3. / A member cannot be registered as an eligible dependant under The Program.
4. / A member may elect to register or deregister a dependant at any time.
5. / If a person requests to be removed from The Program, Defence must action that request within a reasonable period of time.
6. / Information about members and their dependants that is collected by The Program is dealt with in accordance with the Privacy Act 1988.

8.8.8Life of the benefit

1. / Benefits under The Program are only payable on claims submitted within 12 months of the services or products being provided.
2. / This means that the claimant must submit a claim within 12 months of an eligible dependant receiving a service or product in order to be reimbursed under The Program.

EXPLANATORY STATEMENT

Defence Determination 2014/49

This Determination amends Defence Determination 2005/15, Conditions of service (the Principal Determination), made under section 58B of the Defence Act 1903 (the Defence Act) and in accordance with subsection 33(3) of the Acts Interpretation Act 1901 (AIA Act). Determinations made under section 58B of the Defence Act are disallowable non-legislative instruments and are subject to the interpretation principles in the AIA Act, as modified by section 58B of the Defence Act.

Chapter 8 of the Principal Determination sets out provisions for members of the Australian Defence Force (ADF) and their dependants.

The purpose of this Determination is to reimburse ADF members or their dependants for basic health care costs incurred within Australia by those members' dependants who are registeredunder the National ADF Family Health Program.

Clause 1 of this Determination sets out the manner in which this Determination may be cited.

Clause 2 of this Determination provides that the Determination is taken to have commenced1 January 2014.

Clause 3 specifies that the amendment is made to the Principal Determination, as amended.

Clause 4 adds a new Part 8 to the contents list for Chapter 8 of the Principal Determination.

Clause 5 inserts new Part 8into Chapter 8 of the Principal Determination. The new Part sets out provisions to reimburse members or their dependants for basic health care costs incurred within Australia by their dependants under the National ADF Family Health Program (The Program). The new Part includes the following clauses.

• Clause 8.8.1 provides the purpose of the Part.
• Clause 8.8.2 sets out which members the Part applies in relation to.
• Clause 8.8.3 provides a table defining terms used in the Part.
• Clause 8.8.4 provides that members or their dependants may be reimbursed out of pocket expenses for medical expenses incurred by their dependants for services provided in a general practice setting. There is no set limit on the amount that can be reimbursed as use of general practice service is based on health needs.
• Clause 8.8.5 provides that members or their dependants may also be reimbursed up to $400 each year for out of pocket expenses incurred by dependants for consultations with medical specialists and other specified health professionals, and for the cost of required appliances. It also requires certain information to be provided as part of a claim made under The Program.
• Clause 8.8.6 excludes reimbursement of hospital and institutional accommodation and meal costs.
• Clause 8.8.7 provides what a member must do to register a dependant in The Program.
• Clause 8.8.8 provides a 12 month time limit for reimbursements under The Program. As a legal representative can claim for the member or their dependant, it is unlikely that any person would miss out on reimbursement in the event that the usual claimant is severely ill or dies.

Clause 6 is a transitional clause with effect for a retrospective period to 1January 2014. It provides that a member whose eligible registereddependants have incurred health expenses that would have beenreimbursable under this determination had it commenced 1 January 2014 and the day this determination is signed, may be reimbursed out of pocket expenses, less any reimbursement already made (such as Medicare rebates) for those services.

Criteria are provided for the exercise of discretions under the Principal Determination, as amended by this Determination. Adverse decisions are subject to merits review under the ADF redress of grievance system, including an appeal to the Defence Force Ombudsman.

The retrospective application of this Determination does not affect the rights of a person (other than the Commonwealth) in a manner prejudicial to that person, nor does it impose any liability on such person.

Authority: Section 58B of the
Defence Act 1903

Statement of Compatibility with Human Rights

Prepared in accordance with Part 3 of the Human Rights (Parliamentary Scrutiny) Act 2011

Defence Determination 2014/49, National ADF Family Health Program

This Determination is compatible with the human rights and freedoms recognised or declared in the international instruments listed in section 3 of the Human Rights (Parliamentary Scrutiny) Act 2011.

Overview of the Determination

The purpose of this Determination is to reimburse members for basic health care costs incurred within Australia by their dependants registeredunder the National ADF Family Health Program.

Human rights implications

Right tophysical and mental health.

The protection of a person's right to health engages Article 12 of the International Covenant onEconomic, Social and Cultural Rights. Article 12 guarantees the highest standard of physical and mental health, ensuring minimum health standards for children, the environment and the availability of medical services.

Legitimate objective: Defence members are posted to perform duty in many locations around Australia and in overseas locations. They are often required to perform duty in conditions that can include, but

are not limited to, hazard, stress, climate, health care facilities, infrastructure and isolation. Members are often separated from their dependants for Service reasons.

Reasonable, necessary and proportionate: Defence recognises the commitment and sacrifice Defence members make for the nation. The Program reimburses some of the out of pocket medical expenses incurred by the dependants who support these members.

Conclusion

This Determination is compatible with human rights because it advances the protection of human rights.

Christon Scott Chamley, Acting Director General People Policy and Employment Conditions