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Medical Treatment Overseas Program

Guidelines for Applicants

Guidelines for Applicants - Financial Assistance to Australian Residents Requiring Medical Treatment Overseas

Printable version of Guidelines for Applicants (PDF 55 KB)

Printable version of MTO Program Application Form (PDF 93 KB

If you have any difficulty accessing the PDF, please contact MTOP.

Introduction

The Commonwealth may assist persons suffering from a life threatening condition, who require overseas medical treatment, by way of a payment under a program within the auspices of the Department of Health and Ageing. Financial assistance is approved by the Minister for Health and Ageing, or his delegate, following a recommendation from a departmental medical adviser that the applicant meets the criteria set out in (1) below.
These guidelines are intended for distribution to prospective applicants and their medical advisers.

1. Criteria

The applicant must be an Australian Citizen or a legally permanent resident of Australia and (eligible for Medicare benefits).

The following medical criteria must also be met:

A) The proposed overseas treatment or an effective alternative treatment must not be available in Australia in time to benefit the applicant.

Non availability of treatment means that the capacity, knowledge, skills, facilities, etc are not available in Australia, and are not likely to be available within a reasonable period. So, for example, if an applicant requires a particular transplant but a suitable donor organ is not available in Australia, the applicant would not satisfy this criterion if the technical capacity to provide the treatment is available in Australia.

It is therefore essential that applicants seeking financial assistance establish that treatment is not available in Australia. The treating specialist involved in the supporting application should advise of the efforts they have made to determine the availability of both the proposed overseas treatment and alternatives available in Australia. Further independent checks will be made by the Department of Health and Ageing in assessing the application.

While a specific treatment may not be available, other treatment options may be performed in Australia. It must be demonstrated that the proposed treatment will provide a significant improvement over any alternative treatment available in Australia.

B) The treatment must be significantly life extending and potentially curative.

For this criterion to apply the condition suffered by the applicant must be life-threatening and treatment must offer life extending and potentially curative outcomes. It does not require normal life expectation after treatment, but the treatment must provide the prospect of either cure or significant extension of life expectancy.

C)There must be a real prospect of success for the applicant.

The proposed treatment must be able to provide a demonstrated prospect of success.

D) The treatment must be accepted by the Australian medical profession as a standard form of treatment for the applicant’s condition.

The treating specialist that is supporting the application must provide evidence that this treatment is accepted by the Australian medical profession as a standard form of treatment with the Australian medical profession.

For criteria (C) to be assessed in the affirmative, it is essential that the treating specialist provide references to scientific publications attesting to the benefits from the proposed treatment and its expected outcomes.

Where relevant, a comparison with alternative treatments should be provided as well as position statements by authorities or relevant Australian colleges.
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2. Financial assistance for approved applicants

If the above medical criteria are met and the application is approved, the applicant may be reimbursed for the following:

• The full cost of reasonable hospital accommodation plus costs of services normally provided by hospitals in Australia for example drugs, dressings, and prostheses etc, related to the approved treatment, less any amount recovered by way of the client’s private health insurance, if applicable. Please note that subsequent treatment or medications, unrelated to the approved treatment, will NOT be covered by the MTO Program. If you require funding for further treatment it will be assessed as a new application.
• The full cost of a return air fare (business class for international flights and economy class for domestic flights) plus fares for one travel attendant (if medically required) to the place of treatment. All airfares will be booked by the MTO Program Manager as fully flexible fares through the Department's travel provider. This is to accommodate any changes in treatment dates or any unforseen treatment complications that may cause flights to be changed.
• Other fares including travelling expenses incurred within Australia associated with travel to and from airports, passport fees, travel insurance and departure tax. In the treating country, fares to and from the hospital only when arriving and leaving will be reimbursed.
• A carer will be approved automatically when the client is under 18 years of age. A travel attendant will be approved for clients when the treating specialist in Australia provides written advice that demonstrates the need for a travel attendant on medical grounds.
• 100 per cent of reasonable non-hospital accommodation expenses for the client and one travel attendant including any necessary accommodation costs incurred before and after hospitalisation at 3.5 star equivalent accommodation.
• Reimbursement will only be made to clients for the above mentioned costs where proof of expenditure can be provided. This needs to be in the original form of a paid account or receipt relating to eligible medical, hospital, travel, transport and accommodation expenses incurred or a credit card statement that identifies the client’s name, the expense, the amount paid and the date the account was settled. Failure to provide adequate proof of expenditure will prevent the Department from reimbursing clients.
• The Commonwealth will provide financial assistance to the family of any MTO client who dies overseas while being treated, to transport the deceased client home to Australia.

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3. Method of Application

Applications must be submitted on the MTO program application form. Applicants should 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 specialist that has supported the completion of the application MUST sign where specified on the application form.

Please allow a minimum of 6 weeks to process an application. This allows time for the Medical Adviser’s assessment, consultation with relevant colleges and medical groups and then for a package of information to be provided to the decision maker.

Applications are processed as quickly as practicable, given the nature of the program, and all applicants will be notified by formal written advice once the delegate has made a decision.

Please note that at certain times of the year (Christmas & Easter) this time period may be longer due to the unavailability of medical clinicians, who are required to advise in the assessments.

4. Assessment Process

All applications received by the MTO Program, will be acknowledged in writing within 7 days of receipt. A Medical Adviser from the Department of Health and Ageing will then conduct an assessment of the applicant’s condition and proposed treatment. This assessment includes consultation with relevant college/s and medical groups. If the Medical Adviser’s assessment is favourable, a recommendation will be made to the Minister’s Delegate.

Once the Minister’s Delegate has made a final decision, applicants will be notified by a formal written letter.

Negative medical assessment

If the Department’s Medical Adviser’s assessment is unfavourable, the applicant will be given a copy of the Medical Adviser’s assessment, including clinical information and advice obtained through the assessment process.

The applicant will then be given 21 days to provide any additional information in support of their application. Additional information will be considered by the Medical Adviser in a final assessment before proceeding to the Minister’s Delegate for a final decision.

Appealing Minister’s Delegate decisions

If an applicant wishes to appeal the decision made by the Minister’s Delegate, regarding their application for financial assistance under the MTO Program, they must do so in writing within three months of the date of the final decision.

Applicants appealing a decision must provide a letter stating they wish to appeal the decision, the reason behind the appeal and provide relevant supporting documentation.

It is recommended that applicants consult their Australian treating specialists for assistance in providing supporting documentation required for an appeal, to ensure the information is relevant and medically/scientifically based.

Appeals will be considered by the Chief Medical Officer within the Department of Health and Ageing, who is not involved in the initial assessment. The applicant will be advised of the Chief Medical Officer’s assessment and if the appeal 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 a recommendation will be made by the Chief Medical Officer to the Secretary of the Department of Health and Ageing.

The Secretary will make the final decision in relation to the appeal as the Minister for Health and Ageing’s Delegate.

Please note that an appeal will only be conducted once per application. The Secretary’s decision is final and not subject to further appeal.

Letter of appeal and supporting documentation should be sent to:

The Administrator
Medical Treatment Overseas Program
Medical Benefits Division
MDP 850
Department of Health and Ageing
GPO Box 9848
Canberra ACT 2601

Retrospective Claiming

Retrospective claims will only be accepted up to two years from the treatment commencement date. Retrospective applications are assessed on treatment available at the time the applicant undertook treatment not at the time of application.

Travel and Treatment prior to assessment and approval/non approval

Applicants travelling overseas to receive treatment, prior to their application being assessed, do so at their own risk. The Commonwealth does not look more leniently on retrospective claims made after treatment has been received. Any costs incurred will remain the applicant’s responsibility until their application has been approved.

Commencing treatment

Following approval for financial assistance, the treatment regime is required to commence within six months of the approval date.

If treatment has not commenced within six months of the approval date, MTO clients will need to reapply for approval and provide reasons for not commencing the treatment, following the initial approval.

5. Public Appeals - Community Raised Moneys

Where community raised funds are available, the amount of government assistance will be reduced by the balance of community money available after additional reasonable ‘unapproved’ costs to the client have been met.

The department has no control over the disbursement of these moneys, but will require evidence of their disbursement prior to acquittal. All clients are required to complete and sign a declaration stating that any funds raised via public appeals/donations will be utilised before applying for government funding.
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6. Confidentiality

Details of all applications will be treated in accordance with the requirements of the Privacy Act 1988. This means that the Department will generally not discuss the details of an application with anyone, on behalf of an applicant, unless the Department has written authorisation from the applicant, naming those persons that information can be provided to. This is of particular concern where an applicant may have sought support from a broad range of community and outside parties who may try to contact the MTO Program for updates on the application or treatment.

During the assessment process the Commonwealth’s Medical Adviser may need to discuss the application with the applicant’s supporting Australian and overseas specialist. Authorisation for these discussions is assumed, unless the applicant specifically advises MTO administrators otherwise.

The MTO administrators maintain the confidentiality of all application information provided. Please disclose ALL relevant information when completing the application form and during the ongoing treatment process. Failure to disclose all information may affect the final assessment of your application or ongoing financial support.

The Commonwealth requests that you keep the MTO administrators fully informed if there is any media involvement with your circumstances.

If an applicant is approved for financial assistance, MTO Administrators may request a treatment report, following the completion of your treatment, from your 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 e.g. unexpected postoperative care or reviews.
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7. What Does the Commonwealth Medical Treatment Overseas Program Financial Assistance Cover?

Below is a detailed list of the areas Commonwealth financial assistance will, and will not, cover with an approved application for overseas medical treatment.
The Commonwealth will pay for:

• Flights for the client and an approved travel attendee;
• 100% of accommodation costs for the client and an approved travel attendee at a 3.5 star equivalent hotel/motel;
• Travel costs to and from the airport for the client and an approved travel attendee, both in Australia and the treating country;
• Travel taxes for client and an approved travel attendee;
• Travel insurance for client and an approved travel attendee;
• Passports and visas for client and an approved travel attendee, only if the client and travel attendee 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.

The Commonwealth will not pay for:

• 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 client and approved travel attendee, during inpatient or outpatient treatment;
• Living expenses (consumables) such as food;
• Transport or accommodation expenses for any unapproved travel attendee;
• Medications not prescribed by the overseas treating specialist; and
• Post operative care received in Australia.

Any other costs incurred during the treatment process need to be cleared with the Program Manager for clarification on whether they will be covered by financial assistance.

Please be advised that successful applicants, and their approved travel attendee, who currently receive social security or government payments may be affected during their period of travel overseas for treatment. It is the applicant’s responsibility to notify Centrelink, Department of Family and Community Services and Indigenous Affairs, or other appropriate authorities, of their intention to travel outside Australia for any extended period of time.

8. Proposed Treating Facility

As part of the assessment process the Department’s Medical Adviser 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 required.

If the required treatment can be undertaken at an alternative treatment facility, to a similar quality of outcome but at a lower cost than originally proposed, the Medical Adviser may recommend that the applicant be reimbursed up to the lesser amount only. In that case, the applicant will be reimbursed up to the cost of the least expensive treatment option/facility, regardless of which treatment option/facility the client actually undertakes. This is to ensure a cost effective use of Commonwealth funds.

Useful Links

MTO Program Application Form (PDF 93 KB
Guidelines for Applicants (PDF 55 KB)

The documents linked to this page are in PDF format. If you are unable to view them, please contact the Medical Treatment Overseas Program Administrator and a copy will be sent to you.
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