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IntroductionThe Australian Government may assist persons suffering from a life-threatening condition who require overseas medical treatment by way of financial assistance under the MTOP administered by the Department of Health. Financial assistance may be approved by the Minister for Health, or the Minister’s Authorised Officer (the Authorised Officer), following advice from a Panel of Departmental Medical Advisers that the medical evidence submitted by or in relation to the applicant meets the mandatory medical eligibility criteria set out below.
1. Eligibility CriteriaTo qualify for assessment under the Program, the applicant must be an Australian citizen or an ‘Australian resident’, as defined in subsection 3(1) of the Health Insurance Act 1973 (i.e., the applicant must be eligible to receive Medicare benefits), must reside in Australia and must be suffering from a life-threatening condition. The Department of Health will liaise with the Department of Human Services (DHS)-Medicare about the applicant’s eligibility for Medicare, for the purpose of determining the applicant’s eligibility for Australian Government financial assistance to receive medical treatment overseas. To be eligible to receive financial assistance under the MTOP, the applicant will need to provide evidence addressing each of the four (4) mandatory medical eligibility criteria set out below. That evidence will be assessed by Departmental Medical Advisers as to whether those four medical criteria are met. If the Departmental Medical Advisers do not assess the application as meeting each of these four mandatory medical eligibility criteria they will recommend to the Minister, or the Authorised Officer that financial assistance not be provided to the applicant.
Mandatory Medical Criteria:
(a) The proposed overseas treatment or an effective alternative treatment must not be available in Australia in time to benefit the applicant
Treatment will be regarded as being ‘available in Australia in time’ if the capacity, knowledge, skills and/or specialist facilities required to deliver the treatment are available in Australia, or are likely to be available in Australia within a period of time that is likely to be of benefit the applicant.
The MTOP is not available for overseas travel for the purposes of obtaining medical advice or a medical assessment prior to a definitive treatment plan. The application must be for a specific treatment of a specified life-threatening condition.
While a specific treatment may not be available, other treatment options may be available in Australia. It is therefore essential that applicants seeking financial assistance establish that neither the proposed treatment, nor an effective alternative treatment, is available in Australia.
The Australian treating specialist involved in supporting the application should advise of the efforts they have made to confirm that neither the treatment proposed to be obtained overseas nor effective alternative treatments are available in Australia.
Further evidence may also be sought from independent medical experts, the applicant, and/or Australian and overseas treating practitioners and facilities by the Department of Health in the course of assessing the application.
To meet this criterion, the applicant must demonstrate that the proposed overseas treatment is likely to provide a significant improvement in health outcome compared to any alternative treatment available in Australia.
(b) The treatment must be significantly life extending and potentially curativeFor this criterion to be met, the applicant must provide evidence that their condition is life-threatening and that the outcome of the proposed treatment offers a significant extension of life expectancy and the prospect of a cure.
This criterion does not require evidence of normal life expectancy after treatment, but the treatment must provide both the prospect of cure and a significant extension of life expectancy.
The proposed treatment should not be merely palliative in nature or simply aimed at providing effective symptom control for the life-threatening condition.
An application must contain evidence, including the results of medical examinations or assessments, which indicate that:
- the condition is life-threatening; and
- the applicant has a realistic prospect of a cure and a significant extension of life expectancy from the proposed treatment.
(c) There must be a real prospect of success for the applicantClinical evidence must be provided to demonstrate that the proposed treatment has a strong probability of success for the individual applicant. This should include medical evidence regarding the stage of the applicant’s medical condition, the results of any prior treatment, and any significant co-morbidities.
The supporting Australian treating specialist should provide information regarding the patient’s prognosis without the proposed treatment, with alternative treatments available in Australia (if any), and with the proposed overseas treatment.
(d) The treatment must be accepted by the Australian medical profession as a standard form of treatment for the applicant’s conditionThe applicant must provide evidence that this treatment is accepted by the Australian medical profession as a standard form of treatment. For example, the applicant’s supporting Australian treating specialist could provide position statements published by relevant Australian medical expert groups.
Where relevant, a comparison with alternative treatments should also be provided.
The MTOP has been established to assist patients to gain access to treatments accepted as effective by the Australian medical profession but is not available to support individuals wishing to receive experimental treatments or to participate in a clinical trial.
Generally, the results of clinical trials are published in reputable medical journals before the medical profession in Australia accepts a new therapy as a standard form of treatment. This is because the publication process involves peer review by relevant experts to assess the quality and validity of reports of clinical trials and their suggested results.
In assessing the application, the Department of Health may also seek information or opinion from relevant professional organisations or professional medical experts. A de-identified copy of the application submitted by the applicant may be provided to the craft group.
Administrative Eligibility:Applicants will not qualify for an assessment against the four mandatory medical eligibility criteria under the MTOP where:
- the applicant is not eligible for Medicare; or
- the application has not been supported by the applicant’s Australian treating specialist; or
- is no treatment plan presented; or
- the proposed treatment is not for a life-threatening condition; or
- the treatment is palliative in nature and not with curative intent; or
- there is insufficient medical and clinical information presented to undertake an assessment; or
- the application is for participation in a clinical trial or to receive experimental treatment; or
- the applicant has not submitted a proton versus photon comparison plan with the application for proton beam therapy.
2. Assistance to eligible applicantsIf the above mandatory medical eligibility criteria are met and the application is approved, the applicant may be reimbursed for the following -
(i) The full cost of reasonable hospital accommodation plus costs of services normally provided by hospitals in Australia for example medications, dressings, and prostheses etc, related to the approved treatment, less any amount recovered by way of the applicant’s private health or other insurance claim, a compensation settlement, charitable funding or any other source specifically provided for the purpose of accessing medical treatment overseas, if applicable.
Please note that subsequent treatment or medications, unrelated to the approved treatment, will not be covered by the MTOP whether rendered in Australia or overseas. If an applicant requires funding for further treatment or if the treatment plan changes upon presentation to the overseas facility, it will be assessed as a new application.
(ii) The full cost of a return air fare (business class for international flights and economy class for domestic flights) for the applicant plus fares for one travel attendant (if medically required) to the place of treatment.
All airfares will be booked by the MTOP Administrator as fully flexible fares through the Department of Health’s travel provider. This is to accommodate any changes in treatment dates or any unforeseen treatment complications that may cause flights to be changed.
(iii) Other fares including travelling expenses incurred within Australia associated with travel between the applicant’s home and nearest airport, passport fees, travel insurance and departure tax. In the treating country, fares to and from the airport to the treating facility or accommodation on the day of arrival and day of departure only will be reimbursed.
(iv) A carer will be approved automatically if the funding recipient is less than 18 years of age.
A travel attendant may be approved for an applicant if the treating specialist in Australia provides written evidence that sufficiently demonstrates the need for a travel attendant on medical grounds.
(v) 100 per cent of reasonable non-hospital accommodation expenses for the funding recipient and one travel attendant, if the attendant is medically necessary, including any necessary accommodation costs incurred immediately before and after hospitalisation at a reasonable 3.5 star equivalent accommodation facility.
(vi) Reimbursement will only be made to funding recipients for the above mentioned costs if proof of expenditure is provided in the form of properly rendered and legally acceptable invoices and receipts relating to their eligible medical, hospital, travel, transport and accommodation expenses incurred in relation to the approved medical treatment within. These documents are required to be submitted, either electronically or by post, within 30 days of return to Australia following treatment, or as earlier requested by the Commonwealth. Paper or electronic copies of documents submitted to the Department must be true and clear reproductions of the originals.
Documents that are submitted electronically are required to be emailed from the email address the applicant provided on the MTOP Application form.
Failure to provide adequate proof of expenditure will prevent the Department from reimbursing funding recipients.
(vii) Applicants are required to keep electronic or hard copy versions of all of documents relating to their application, including invoices and receipts, in case they are required for audit purposes in the future.
(viii) The Australian Government will provide financial assistance to repatriate the remains home to Australia of any MTOP funding recipient who dies overseas while undergoing their approved medical treatment.
In this circumstance Australian Government financial assistance does not include the reimbursement of costs that would have been incurred in Australia, such as cremation of the deceased remains, purchase of caskets or funeral home fees.
Accompanying Medical Attendant
A medical attendant will not be approved unless the Australian treating specialist provides satisfactory evidence that a medical attendant is necessary, indicates the type of medical support required, the duration of that support and also provides details of the clinical qualifications and/or skills the medical attendant must have in order to support the applicant while travelling, and while overseas.
If the Australian treating specialist has certified that a medical attendant with clinical qualifications is required (for example, a registered nurse) the cost of that medical attendant’s salary and expenses while accompanying the applicant while travelling and if reasonably necessary while overseas, may be reimbursed.
If the Australian treating specialist has certified that a medical attendant is necessary but does not require clinical qualifications and the applicant does not engage a paid medical attendant for the purposes of providing medical support while they are travelling overseas (for example, a relative or friend of the applicant provides the medical support) only the approved expenses incurred by the medical attendant will be reimbursed.
3. Method of applicationApplications must be submitted on the MTOP application form.
If an applicant is less than 18 years of age a parent or guardian may complete the application form and sign the applicant’s declaration.
If the applicant is unable to complete and sign the application form for medical reasons, evidence of legal guardianship must be provided.
Applicants must seek the assistance of the specialist(s) from whom they are receiving treatment in Australia to complete the application and provide supporting medical documentation.
The application will not be accepted unless the specialist who has supported the completion of the application has signed where specified on the application form.
Please allow a minimum of 6 weeks to process an application. This allows time for the assessment by a Panel of Departmental Medical Advisers, consultation by the Department with relevant medical expert groups with expertise in the applicant’s particular condition and the outcome of the assessment to be prepared for and considered by the Minister or the Authorised Officer.
Applications are assessed as quickly as practicable, given the nature of the program, and all applicants will be notified by formal written advice once the Minister or the Authorised Officer has made a decision.
4. Assessment processAll applications received by the MTOP will be acknowledged in writing within 7 days of receipt.
Once an application has been determined to be eligible for assessment, a Panel of Medical Advisers in the Department of Health will then conduct an assessment of the applicant’s condition and proposed treatment against the four mandatory medical eligibility criteria.
This assessment may include consultation with relevant medical expert groups about the applicant’s condition, their medical status and the treatment proposed. If the Panel of Medical Advisers concludes that all of the four mandatory medical eligibility criteria have been met, advice will be provided to the Minister or the Authorised Officer (usually a Deputy Secretary within the Department of Health).
In making a decision about an applicant’s eligibility for assistance under the MTOP the decision-maker must also be satisfied under Section 23(3) of the Public Governance, Performance and Accountability Act 2013, after making such inquiries as are reasonable, that the proposed expenditure is in accordance with the policies of the Commonwealth and that it will make efficient, effective, economical and ethical use of public money.
The decision-maker may, for example, consider that the approval of Commonwealth funds in circumstances where the applicant is in receipt of an insurance or compensation settlement specifically for the treatment of the life-threatening condition would not be a proper use of public money, even though the applicant meets all the mandatory medical eligibility criteria.
If the decision-maker proposes to reject an application in circumstances where the Panel of Medical Advisers has advised that the application meets all the mandatory medical eligibility criteria, the applicant will be informed of that fact and the reasons for which the decision-maker proposes to reject the application. The applicant will be given 21 days to respond before a decision is made.
Once the Minister or the Authorised Officer has made a final decision, applicants will be notified by a formal written letter.
Negative medical assessment
If the Department’s Panel of Medical Advisers concludes that the applicant does not meet one (or more) of the four mandatory medical criteria, the applicant will be given a copy of the draft (negative) medical assessment, including clinical information and advice obtained through the assessment process. The applicant will then be given 21 days to provide comment on the draft assessment and to submit any additional information in support of their application. It is recommended that applicants consult with their Australian treating specialist in preparing their response to the draft assessment.
All information submitted by the applicant in response to the draft assessment will be considered by the Panel of Medical Advisers in finalising the assessment before proceeding to the Minister or the Authorised Officer for a final decision.
This process may include (further) consultation with relevant medical expert groups about any additional information submitted by, or on behalf of, the applicant in relation to their application.
If no response is received by the end of the prescribed 21 day period, the assessment will be finalised and advice provided to the Minister or the Authorised Officer for a final decision.
Seeking review of the Minister’s Authorised Officer decision
If an applicant wishes to seek review of the decision made by the Minister’s Authorised Officer, regarding their application for financial assistance under the MTOP, they must do so in writing within three (3) months of the date of the final decision.
Applicants seeking review of a decision must provide a letter stating they wish to seek review of the decision, the reason behind the review and provide relevant supporting documentation.
It is recommended that applicants consult their Australian treating specialists for assistance in providing supporting documentation required for a review, to ensure the information is relevant and medically/scientifically based and addresses the mandatory medical eligibility criteria.
Reviews will be considered by the Australian Government’s Chief Medical Officer (CMO) within the Department of Health, who is not involved in the initial assessment. The applicant will be advised of the CMO’s assessment and if the review application is not supported, the applicant will be given an additional 21 days to comment or submit further documentation.
On receipt of any additional material from the applicant, advice will be provided by the CMO to the Secretary of the Department of Health about whether, following assessment of all the available information and after any further consultation considered necessary by the CMO, the applicant has met the four mandatory medical eligibility criteria. The Secretary will make the final decision in relation to the review as the Authorised Officer for the Minister for Health.
A review will be conducted once per application. The Secretary’s decision is not subject to further internal review. Judicial review by the Federal Court of Australia might be available in some circumstances.
While applications may be considered after the overseas treatment has been completed, such applications will only be accepted up to two (2) years from the treatment commencement date.
Retrospective applications are assessed against the four mandatory medical eligibility criteria for the treatment available at the time the applicant undertook treatment, not at the time of application.
For retrospective applications, evidence of expenses must be provided in accordance with these Guidelines. If the application is approved, allowable expenses will be reimbursed at the exchange rate prevailing on the date of the invoice or other suitable evidence of expenditure. Airfares will be reimbursed at the lesser of either the “best fare of the day” as determined by the Department’s travel provider or the fare paid by the applicant.
Applicants should note that any overseas travel and medical treatment undertaken prior to approval of an application is done so at the applicant’s own risk and expense.
Following approval for financial assistance, the treatment regime is required to commence within six (6) months of the approval date.
If treatment has not commenced within six (6) months of the approval date, the funding recipient will need to reapply for funding assistance under the MTOP and provide reasons for not commencing the treatment, following the initial approval.
5. Proposed treating facilityAs part of the assessment process, the Department’s Panel of Medical Advisers will take into consideration the proposed treatment and treatment facility and will undertake a comparison of other treatments and treatment facilities that could provide the same treatment overseas.
If the required treatment can be undertaken at an alternative treatment facility, to a similar quality of outcome but at a lower cost than the facility proposed by the applicant, the applicant may be reimbursed up to the cost of the least expensive treatment option/facility, regardless of which treatment option/facility the funding recipient actually chooses. This is to ensure a cost effective use of Australian Government funds.
6. Funding received from other sourcesApproved applicants may receive funding from other sources including their private health fund or from compensation schemes. Approved applicants may also receive financial support to assist in receiving the overseas treatment from funds raised in the community including through public donations or support from charitable organisations.
Approved applicants will be required to utilise funding received from any of these sources in payment of medical or related expenses first and only use Australian Government funds provided under the MTOP as a last resort. Following the funding recipient’s return home to Australia after treatment, the funding recipient will be required to utilise any remaining funds from other sources prior to seeking reimbursement from the Australian Government for funds under the MTOP.
Funding recipients must provide details of any other money recovered or recoverable from private health funds or any other source including through a tax offset, Centrelink payment, payments from other Australian Government or State authorities, insurance claims (eg., private health insurance, travel, workers’ compensation or third party claims) or, if applicable, under the Early Release of Superannuation Benefits Program, in relation to their approved medical treatment and costs incurred in obtaining the treatment overseas.
All funding recipients are required to complete and sign a declaration stating that any funds raised via public appeals/donations or any other source as described above will be utilised before seeking Australian Government funding for, or reimbursement of, the approved treatment and costs incurred in obtaining the overseas treatment. All funding recipients may be required to sign an authority allowing the Australian Government to obtain from a relevant third party information and documentary evidence about such funds and the way in which they have been spent.
The amount of Australian Government funding provided may be reduced in light of other funds received as a result of the funding recipient’s condition or proposed treatment. In some cases, for example, where a lump sum compensation payment or other entitlement is received by the funding recipient after treatment has occurred and in respect of the condition treated, funding may be required to be reimbursed to the Australian Government.
Where the Australian Government has provided funds to meet eligible costs in relation to treatment, and those funds have not been expended for that purpose, the funding recipient will be required to repay those funds within 30 days of request by the Australian Government, or of the funding recipient’s return to Australia, whichever comes first.
If the funding recipient is eligible or has received a payment under an insurance or compensation scheme as described in paragraph 18 (1) (b) of the Health Insurance Act 1973, the amount received must:
(a) to the extent it has not already been applied in paying medical or treatment expenses in Australia, be applied in paying any medical expenses which might otherwise be met under the MTOP before payment is sought from the Commonwealth for those expenses; and
(b) to the extent it has not already been applied in paying medical or related expenses which are the subject of an application under the MTOP, be paid to the Commonwealth to reimburse it up to the amount paid out under the MTOP.
Applicants in Receipt of a Pension or Benefit
The eligibility of funding recipients (or their approved medical attendant) who currently receives Centrelink or other Australian Government payments may be affected during their period of travel overseas for treatment.
It is the funding recipient’s responsibility to notify Centrelink, or any other relevant authority, of their intention to travel outside Australia for any extended period of time.
7. ConfidentialityThe MTOP Administrators maintain the confidentiality of all application information received, subject to limited exceptions noted below in section 8. Please disclose ALL relevant information when completing the application form and during the ongoing treatment process. Failure to disclose all relevant information may affect the final assessment of an application or the amount of financial support provided.
8. PrivacyThe MTOP collects personal information about an applicant for the purpose of determining whether the applicant is eligible for financial assistance under the MTOP and for administrative purposes. All personal information collected by the MTOP is treated in accordance with the requirements of the Privacy Act 1988 (Privacy Act).
In accordance with the Privacy Act, the application form for financial assistance for medical treatment overseas includes a Privacy Notice (Part B). The Privacy Notice explains, amongst other things, why personal information about the applicant is collected and to whom it may be disclosed.
As set out in the Privacy Notice, the MTOP may disclose personal information about an applicant to:
- an individual the applicant nominates as someone who can receive information about his or her application to, and participation in, the MTOP
- the Department of Human Services for the purpose of determining eligibility for Medicare benefits
- the referring Australian treating specialist
- the proposed overseas treating specialist
The Department may also disclose de-identified information relating to an applicant’s medical condition to medical expert groups. If the applicant’s medical condition is rare, the applicant may be identifiable in these circumstances.
9. Follow-up contact in relation to approved applicantsIf an applicant is approved for financial assistance, the MTOP Administrator will require a treatment report, following the completion of treatment, from the overseas treating specialist. This report will be used to highlight any treatment issues that may need to be taken into consideration for future financial assistance, such as post-operative care.
The Department may further seek to confirm the current medical status of an approved funding recipient between 12 months and 24 months after the overseas treatment has been completed to confirm the medical status of the applicant and the success of the treatment in treating the applicant’s condition.
10. What does the Commonwealth MTOP financial assistance cover?Below is a detailed list of the areas Australian Government financial assistance under the MTOP will and will not cover with an approved application for overseas medical treatment.
The Commonwealth will pay for:
- flights for the funding recipient and an approved travel attendant (where medically supported or the funding recipient is under 18);
- 100% of accommodation costs for the funding recipient and an approved travel attendant at a reasonable 3.5 star equivalent accommodation facility;
- reasonable travel costs to and from the airport for the funding recipient and an approved travel attendant, both in Australia and in the treating country; travel taxes for the funding recipient and an approved travel attendant, where applicable;
- travel insurance for the funding recipient and an approved travel attendant;
- passports and visas for the funding recipient and an approved travel attendant, only if the funding recipient or approved travel attendant do not already hold a current passport that will remain current for six months after the treatment date; and
- medical costs associated with the approved treatment for the specified life-threatening condition for the approved funding recipient.
- any diagnostic or medical treatment received in Australia in preparation for treatment overseas;
- routine travel to and from the hospital in the treating city for the funding recipient and approved travel attendant, during inpatient or outpatient treatment;
- day-to-day living expenses (consumables) such as food, room service, telephone, internet access, cleaning or washing services, car hire etc;
- medical consultations or treatment required for the approved travel attendant;
- transport or accommodation expenses for any unapproved travel attendant;
- medications not prescribed by the overseas treating specialist;
- subsequent overseas travel for review at the treatment facility; and
- post-operative care received in Australia.
Change of treatment plan
If the funding recipient’s treatment plan changes on presentation to the overseas treating facility, the MTOP Administrator must be informed immediately.
A new application for assistance under the MTOP may be required, which will be assessed against the mandatory medical eligibility criteria to determine whether the funding recipient remains eligible for Australian Government financial assistance.
Financial support for a parent or guardian
If the funding recipient is under eighteen (18) years of age, then the approved expenses of one parent or guardian will be met under the MTOP. The parent’s or guardian’s travel and accommodation expenses only will be met on the same basis as the funding recipient’s.
Medical treatment required by a parent or guardian at an overseas facility, either as a result of a pre-existing medical condition or as a result of an accident or onset of illness in the treating country, is not eligible for financial assistance.
11. Acquittal ProcedureFunding recipients must submit properly rendered and legally acceptable invoices and receipts relating to their eligible medical, hospital, travel, transport and accommodation expenses incurred in relation to the approved medical treatment. These documents are required to be submitted, either electronically or by post, within 30 days of return to Australia following medical treatment, or otherwise requested by the Australian Government. Paper or electronic copies of documents submitted to the Department must be true and clear reproductions of the originals.
Documents that are submitted electronically are required to be emailed from the email address provided by the applicant on the MTOP Application form.
If adequate proof of expenditure is not provided, the Department will not reimburse funding recipients.
Applicants are required to keep electronic or hard copy versions of all documents relating to their application, including invoices and receipts for eligible expenditure claims, for a period of five (5) years, in case they are required for audit purposes in the future.
For acquittal purposes, funding recipients must provide to the Department of Health details of all monies recovered or recoverable from private health funds or from other sources including tax offsets, Centrelink payments or payments from other Commonwealth or State authorities, insurance (eg, travel or third party), compensation payments, public fund raising, donations and/or charitable funds, or the Early Release of Superannuation Benefits Program, within 30 days of return to Australia following treatment, or earlier as requested by the Australian Government.
If requested, funding recipients must provide the Department of Health with a written authority to obtain any documents relating to monies recovered or recoverable from any source listed above, from any relevant person.
Expenses will be reimbursed in Australian dollars at the exchange rate prevailing at the date the cost was incurred (date of invoice).
12. Contacting the DepartmentAll contact with the Department of Health should be with the MTOP Administrator, Medical Treatment Overseas Program. Applications should be sent to:
The MTOP Administrator
Medical Treatment Overseas Program
Medical Benefits Division
Department of Health
GPO Box 9848
Canberra ACT 2601
Email enquiries should be directed to: MTOP inbox
Telephone enquiries should be directed to: (02) 6289 7496 (from overseas: 0011-61-2-6289 7496).