The Act and the Rules explain what a registered provider must do to claim a subsidy. The exact requirements depend on the service group or if the services are being delivered through a specialist aged care program.
[Chapter 4 – Part 2 – Division 6]
To claim a subsidy, providers must be registered and eligible for subsidy for the delivery of a funded aged care service to an older person. Different service groups have different eligibility requirements for subsidy, which are set out in the Act and the Rules.
The process to claim subsidies is different for services delivered in the 3 home or community service groups compared to residential care.
Claiming subsidies in home or community settings
Providers have to submit claims for subsidy payments for person-centred and provider-based subsidies in home or community settings. This is based on the eligible subsidy amount, but the actual amount they receive is not necessarily the same as the eligible amount.
The information in the Guide sets out the process for how subsidy claims work in line with the Act. The Support at Home program manual provides more information about the process to make a claim for home support services in practice.
Person-centred subsidies – home or community settings
Working out how much person-centred subsidy a provider is eligible for is the first step to claiming a subsidy. The actual amount paid depends on the amount of funding in the older person’s ‘account’ for services.
Accounts
An ‘account’ in the Act isn’t an actual bank account with money going in and out. It’s a record of how much funding someone is entitled to.
Older people may have up to 3 accounts that record how much funding they are entitled to for a service:
- Service group account
- Unspent Commonwealth portion
- Home care account
The government must check each of these when they work out how much subsidy they need to pay once a provider makes a claim.
The service group account is a new account that will be created as the main record for someone’s funding for the aged care services they receive under the Act. Each service group has a corresponding service group account:
- Home support account
- Assistive technology account
- Home modifications account.
The unspent Commonwealth portion and the home care account – called transitional accounts in the Guide - carry over funding an older person was entitled to under the previous aged care system.
Available balance
The amount available in each account is called the available balance. Providers will make their claim for the eligible subsidy amount against the available balance in the older person’s account/s. The available balance can’t go below zero.
- ‘Credits’ are added to the account based on the funding someone is entitled to.
- ‘Debits’ are deducted from the account when subsidy has been paid for a service.
The Rules set out the amounts to be credited to service group accounts, based on someone’s:
- service group, classification type and classification level – called the base individual amount for home support or tier amount for assistive technology and home modifications
- primary person-centred supplements – supplements are extra amounts that an older person may be entitled to. Primary person-centred supplements are credited to the available balance in line with the Act and the Rules.
The Act and Rules explain how and when an account is credited based on the service group and classification type. Slightly different arrangements apply for the transitional accounts.
Ongoing home support services have specific rules for ‘rolling over’ credits to a new period. This is when unused credits in one period are transferred to the next period. The rules for rolling over credits are explained in detail in the Act and the Rules, but there are limits on how much can be rolled over.
Note: When a provider makes a claim, there is an order for debiting the older person’s accounts to pay the claim. The order depends on the service group.
For home support:
- Check the home support account.
- Check the unspent Commonwealth portion.
- Check the home care account.
For assistive technology and home modifications:
- Check the unspent Commonwealth portion.
- Check the home care account.
- Check the assistive technology or home modifications account.
The general principle is the same – to check the total amount of funding available for the person at that time to pay the claim.
Excess
The total available balance of the relevant account/s is the most the government can pay as the final subsidy amount.
If the eligible subsidy amount is more than the total available balance, the government will not pay the difference between the 2 amounts – the excess – in the final subsidy amount.
Note: The provider is still eligible for this excess, even though it was more than the available balance when the provider submitted their claim. This means that if or when additional credit is added to the older person's account at a later time, the provider may be able to claim the excess then. The claim has to be made in line with the requirements and timeframes in the Act and the Rules.
Person-centred subsidy: example
This is a very simple example of how to work out the amount of person-centred subsidy a provider would be paid for the delivery of a funded aged care service to an older person through the service group home support. These numbers are not accurate and are only used to show how each step in the method equals the eligible subsidy amount and final amount paid to the provider. This also assumes there are no contributions from the older person for the services delivered.
Provisional subsidy amount: $150
Secondary person-centred supplement: $0
Add person-centred supplement to provisional subsidy amount (if applicable): $150 + $0 = $150
Therefore, the eligible subsidy amount = $150
The provider submits a claim for the eligible subsidy amount of $150, which is checked against the older person’s available balance/s.
The available balances of the older person’s accounts are:
- Home support account: $100
- Unspent Commonwealth portion: $0
- Home care account: $20
Deduct the claim amount from the available balances in the following order:
- Home support account: $100 - $150 = -$50
$50 excess not covered by home support account - Unspent Commonwealth portion: $0 - $50 = -$50
$50 excess not covered by home support account or unspent Commonwealth portion - Home care account: $20 - $50 = -$30
$30 excess not covered by any of the available balances.
Final amount paid to the provider through the claim: $120
Excess amount: $30
Note: The provider isn’t paid the excess $30 in this subsidy payment, as it’s more than the available balances. But they are still eligible for it, so they may be able to claim it at a later time – in line with the Act and the Rules – if credit becomes available.
Provider-based subsidies – home or community settings
Figuring out how much subsidy a provider is eligible for is the first step to claiming a provider-based subsidy. Similar to person-centred subsidies, the actual subsidy amount a provider is paid depends on the amount of funding in the provider’s ‘account’ for that service.
Accounts
Providers delivering home or community services work through service delivery branches, which are specific locations or sites that the provider operates out of. A provider may have many service delivery branches, or they may only work out of one.
Provider-based subsidies are linked to the service delivery branch, so each branch has a service delivery branch account. There are no transitional accounts for provider-based subsidies.
The department looks at the service delivery branch account to work out how much provider-based subsidy can be paid once a provider makes a claim. The principles for this are the same as for person-centred subsidies, but the ‘account’ is different.
Available balance
The available balance of the service delivery branch account is the balance of credits and debits. When the provider submits a claim for the eligible person-centred subsidy amount, the final subsidy amount the government pays the provider depends on the provider’s available balance. The available balance can’t go below zero.
Service delivery branch accounts receive credits from the:
- base provider amount set out in the Rules, based on the classification level of the older persons receiving services through the service delivery branch
- provider-based supplements – extra amounts that a provider may be entitled to, which are explained in the Act and the Rules.
Provider-based supplements are supplements explained in the Rules that may support the provider to deliver services in certain situations. For example, a provider might receive this supplement if they are delivering funded aged care services to someone who is homeless.
The Rules explain the process for rolling over credits depending on the balance. The way credits are made differ for newly established service delivery branches.
Excess
Even if a provider is eligible for provider-based subsidy the government will only pay the amount of subsidy that is available in the provider’s service delivery branch account. If the eligible subsidy amount is fully covered by the balance in the account, the government pays that amount. However, if the eligible subsidy amount is more than the available balance, the government will not pay the excess.
Note: The provider is still eligible for the excess, even though it was more than the available balance when the provider submitted their claim. They may be able to claim this at a later time, in line with the Act and the Rules, if credits have been added to the service delivery branch account.
Claiming subsidies in residential care
Claiming subsidies in residential care works differently than for services in home or community settings.
Residential aged care providers are paid monthly in advance for the services they deliver. The amount they receive is estimated based on the cohort of older people in the care home, using information from previous months of funding. The provider uses this funding to pay for services for the residents of the care home.
To claim their subsidy, the provider submits their calculated subsidy amount to be reconciled against the amount they have been paid by the government for that period. The department reconciles these amounts and uses this information as the basis to estimate future payment amounts.