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Medical Treatment Overseas Program

Guidelines for Applicants

Guidelines for Applicants - Financial Assistance to Australian Residents Requiring Medical Treatment Overseas. These guidelines are intended for distribution to prospective applicants and their medical advisers.

Printable version of Guidelines for Applicants (PDF 508 KB)

Printable version of MTO Program Application Form (PDF 488 KB)

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

Introduction

The Australian Government may assist persons suffering from a life threatening condition who require overseas medical treatment by way of financial assistance under the Medical Treatment Overseas (MTO) Program administered by the Department of Health and Ageing. Financial assistance may be approved by the Minister for Health, or the Minister's delegate (the Delegate), 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 Criteria

To 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 and Ageing 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 Program, 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 Delegate, 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 MTO Program is not available for applicants seeking overseas treatment because of the non-availability of a suitable donor organ in Australia. A decision maker will therefore not consider the availability of donor organs when considering an application to take part in an organ transplant program that is available in Australia.

The MTO Program 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 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 experts, the applicant, and/or Australian and overseas treating practitioners and facilities by the Department of Health and Ageing 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 curative

For 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.

To assist in the assessment of this criterion, the treating specialist should provide references to published scientific literature demonstrating the benefits from the proposed treatment and its expected outcomes.

(c) There must be a real prospect of success for the applicant

Clinical 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 medical 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 condition

The 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 specialist could provide position statements published by relevant Australian colleges or other authorities.

Where relevant, a comparison with alternative treatments should also be provided.

The MTO Program has been established to assist patients to gain access to treatments accepted as effective by the 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 and Ageing may also seek information or opinion from relevant professional organisations or medical professional 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 Program where:

- the applicant is not eligible for Medicare; or
- where the application has not been supported by the applicant's Australian treating medical specialist; or
- where there is no treatment plan presented; or
- where the proposed treatment is not for a life-threatening condition; or where the treatment is palliative in nature and not with curative intent; or
- where there is insufficient medical and clinical information presented to undertake an
assessment; or
- where the application is for participation in a clinical trial or to receive experimental treatment.
Applicants in this circumstance will be advised that their application has not proceeded to the assessment phase, but will be afforded the opportunity to submit additional information which may lead to an assessment.

2. Assistance to Eligible Applicants

If 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 drugs, 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 MTO Program 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 oftreatment.

All airfares will be booked by the MTO Program Administrator as fully flexible fares through the Department of Health and Ageing'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 original invoices and receipts relating to their eligible medical, hospital, travel, transport and accommodation expenses incurred in relation to the approved medical treatment within 30 days of return to Australia following treatment, or as earlier requested by the Commonwealth.

Failure to provide adequate proof of expenditure will prevent the Department from reimbursing funding recipients.

(vii) The Australian Government will provide financial assistance to repatriate the remains home to Australia of any MTO Program 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 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 ofthe clinical qualifications and/or skills the medical attendant must have in order to support the applicant while travelling, and while overseas.

If the 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 treating specialist has certified that a medial 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 Application

Applications must be submitted on the MTO Program 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 colleges and medical 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 Delegate.

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 Delegate has made a decision.

4. Assessment Process

All applications received by the MTO Program 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 and Ageing 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 college/sand medical 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 Delegate (usually a Deputy Secretary within the Department of Health and Ageing).

In making a decision about an applicant's eligibility for assistance under the MTO Program the decision-maker must also be satisfied under Regulation 9 of the Financial Management and Accountability Act 1997 (FMA Act), 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 Delegate 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 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 Delegate for a final decision.

This process may include (further) consultation with relevant college/sand medical 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 Delegate for a final decision.

Seeking review of the Minister's Delegate decision

If an applicant wishes to seek review ofthe 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 (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 and Ageing, 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 and Ageing 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 Delegate 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.

Retrospective applications

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 orthe 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.

Commencing treatment

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 Program and provide reasons for not commencing the treatment, following the initial approval.
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5. Proposed Treating Facility

As 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 Sources

Approved 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 MTO Program 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 MTO Program.

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 ofthe 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.

Compensation Pavments

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 MTO Program 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 MTO Program, be paid to the Commonwealth to reimburse it up to the amount paid out under the MTO Program.

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. Confidentiality

The MTO Program Administrators maintain the confidentiality of all application information received, subject to limited exceptions noted below. 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.

Details of all applications will be treated in accordance with the requirements of the Privacy Act 1988. This means that the Department of Health and Ageing will generally not discuss the details of an application with anyone unless the Department has written authorisation from the applicant naming those persons to whom information may be provided.

This is of particular relevance where an applicant may have sought support from a broad range of community and outside parties, including media outlets, who may try to contact the MTO Program for information about the applicant or their proposed treatment.

If an applicant's case is the subject of a media report or inquiry, the Department or the Minister may respond, including publicly, to correct or to confirm the content of such a report or inquiry.

During the assessment process the Department's Panel of Medical Advisers may need to discuss the application with the applicant's supporting Australian and overseas specialist(s). The applicant is, by making an MTO Program application, taken to have authorised these discussions, unless the applicant specifically advises the MTO Program Administrator otherwise.

Follow-up contact in relation to approved applicants

If an applicant is approved for financial assistance, the MTO Program Administrator will require a treatment report, following the completion oftreatment, 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 postoperative 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.

8. What does the Commonwealth Medical Treatment Overseas Program Financial Assistance Cover?

Below is a detailed list of the areas Australian Government financial assistance under the MTO Program 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.

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 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.

Advice should be sought from the Program Administrator regarding any other costs incurred
during the treatment process to clarify whether they will be covered by financial assistance under the MTO Program.

Change of treatment plan

If the funding recipient's treatment plan changes on presentation to the overseas treating facility, the MTO Program Administrator must be informed immediately.

A new application for assistance under the MTO Program 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 Program. 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.

9. Acquittal Procedure

Funding recipients must submit properly rendered and legally acceptable original invoices and receipts relating to their eligible medical,hospital, travel, transport and accommodation expenses incurred in relation to the approved medical treatment within 30 days of return to Australia following medical treatment, or otherwise as requested by the Australian Government.

If adequate proof of expenditure is not provided, the Department will not reimburse funding recipients.

For acquittal purposes, funding recipients must provide to the Department of Health and Ageing 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 and Ageing 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).

10. Contacting the Department

All contact with the Department of Health and Ageing should be with the Program Administrator, Medical Treatment Overseas Program. Applications should be sent to:

The Program Administrator

Medical Treatment Overseas Program

Medical Benefits Division

MDP 850

Department of Health and Ageing

GPO Box 9848

Canberra ACT 2601


Email enquiries should be directed to the MTOP inbox.

Telephone enquiries should be directed to: {02) 6289 7496 (from overseas: 0011-61-2-6289 7496)

or facsimile: (02) 6289 3562 (from overseas: 0011-61-2-6289 3562).
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