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Part 9: National ADF Family Health Program

8.9.1 Purpose

The purpose of this Part is to reimburse ADF members or eligible dependants for health costs incurred within Australia by a dependant registered under the National ADF Family Health Program.

8.9.2 Members this Part applies to

  1. This Part applies to the following members with one or more eligible dependants.

    1. Permanent Forces members.

    2. Members of the Reserves on continuous full-time service.

  2. This Part does not apply in relation to health costs incurred by a member or their dependant in any period in which the member is serving as a member of the Reserves and is not on continuous full-time service.

    Note: In the total workforce model, the following arrangments apply.

    1. A member of the Permanent Forces may be described as a member in Service category 6 or 7.

    2. A member of the Reserves on continuous full-time service may be described as a member in Service category 3, 4 or 5 and Service option C.

    3. A member of the Reserves may be described as a member in Service category 2, 3, 4 or 5.

8.9.3 Definitions

This table defines terms used in this Part.

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

8.9.4 General practice setting benefits

  1. A claimant may be reimbursed for all out of pocket expenses incurred by an eligible dependant for medical services provided in a general practice setting.

  2. A service referred to in subsection 1 must have a Medicare Benefits Schedule item number. It does not need to be provided by a general practitioner.

    Example: A nurse practitioner provides the service at the general practice and the out of pocket expenses for it are claimed under The Program.

  3. Despite the limit in subsection 2, if a service could reasonably be expected to attract a Medicare rebate but for the fact that the patient is not eligible for Medicare, the claimant can be reimbursed the full amount of the fee that the general practice charged for that item.

8.9.5 Specialists and allied health benefits

  1. The maximum that may be reimbursed to a claimant under this section for any financial year from 1 July 2015 is $400 for each of a member's eligible dependants.

  2. Reimbursement under this section is limited to the out of pocket expenses incurred by an eligible dependant, for services or products described in paragraphs a, b and c of this subsection, and excluding costs described in subsection 3.

    1. Consultation with a specialist. The service must have a Medicare Benefits Schedule item number.

    2. Medically prescribed, dental and optical appliances.

    3. An allied health service, including any listed in the following table.

    Services
    Item Service Benefit
    1. Audiology Consultation by an eligible audiologist under the Health Insurance (Allied Health Services) Determination 2014.
    See: Health Insurance (Allied Health Services) Determination 2014
    2. Chiropractic and Osteopathy Consultation by a chiropractor or osteopath registered with the Australian Health Practitioner Regulation Agency.
    See: Australian Health Practitioner Regulation Agency website for registered practitioners
    3. Dental Consultation by a dentist registered with the Australian Health Practitioner Regulation Agency. Includes items listed by the Australian Dental Association (ADA).
    See:
    1. Australian Health Practitioner Regulation Agency website for registered practitioners
    2. The Australian Schedule of Dental Services and Glossary for included items
    4. Dietary Consultation by an allied health professional under the Health Insurance (Allied Health Services) Determination 2014.
    See: Health Insurance (Allied Health Services) Determination 2014
    5. Occupational Therapy Consultation by an occupational therapist registered with the Australian Health Practitioner Regulation Agency.
    See: Australian Health Practitioner Regulation Agency website for registered practitioners
    6. Optical Consultation by an optometrist registered with the Australian Health Practitioner Regulation Agency. Includes all prescription eyewear, lenses, frames, contact lenses and repairs.
    See: Australian Health Practitioner Regulation Agency website for registered practitioners
    7. Physiotherapy Consultation by a physiotherapist registered with the Australian Health Practitioner Regulation Agency.
    See: Australian Health Practitioner Regulation Agency website for registered practitioners
    8. Podiatry and Chiropody Consultation by a podiatrist or chiropodist registered with the Australian Health Practitioner Regulation Agency.
    See: Australian Health Practitioner Regulation Agency website for registered practitioners
    9. Psychology Consultation by a psychologist registered with the Australian Health Practitioner Regulation Agency.
    See: Australian Health Practitioner Regulation Agency website for registered practitioners
    10. Speech Therapy Consultation by an allied health professional under the Health Insurance (Allied Health Services) Determination 2014.
    See: Health Insurance (Allied Health Services) Determination 2014
  3. Specialist and allied health services to which either or both the following descriptions apply are not reimbursed under The Program.

    1. They attract goods and services tax (GST).

    2. They are cosmetic.

  4. The benefit may be transferred to other eligible dependants of the member.

    Example: A family of three has registered for The Program and has been allocated a total of $1,200 for the financial year (i.e. $400 maximum per dependant). One of the dependants undergoes extensive physiotherapy. The dependant's annual $400 allocation has been claimed but there is still an amount outstanding. The claimant is able to use part or all of the other dependants' allocation to cover out of pocket expenses, with the understanding that another allocation is not available until the next financial year.

  5. Claimants may be reimbursed for out of pocket expenses under The Program for eligible dependants with private health insurance. The following conditions apply.

    1. Any private health rebate must be claimed before claiming reimbursement under The Program.

    2. The claimant may only be reimbursed the cost of the service, less any Medicare and private health insurance rebates, up to their remaining yearly limit.

    3. The claimant must provide any relevant private health insurance receipts with their claim.

  6. The claimant must provide payment receipts with their claim, in order to be reimbursed under The Program.

  7. In addition to the requirements of subsections 5 and 6, a claimant who seeks reimbursement for a medically prescribed appliance must include a copy of the recommendation or prescription for the item from a registered practitioner.

8.9.6 Hospital and institutional expenses are not reimbursed

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

8.9.7 Registering for The Program

  1. To register a dependant for the purposes of The Program, a member must take all of the following actions.

    1. Ensure the dependant is listed and their details up-to-date in the Dependant/Beneficiary section of Defence's Personnel Management Key Solutions system (PMKeyS). To list or update dependant details the member must use form AD160 – ADF Dependant Details.

      See: Webform AD160 – ADF Dependant Details

    2. Register for The Program using form AD858-1, ADF Family Health.

      See: Webform AD858-1, ADF Family Health

    Notes:

    1. The member will be sent an ADF Family Health Card after dependants have been successfully registered. This card can be used to pay for services at the point of sale where the provider has software installed to enable that.
    2. Because a dependant does not become eligible until after they have been registered on The Program, claims cannot be made for services that are provided on a day before the dependant is registered.

  2. Eligible dependants can only be registered by one ADF member. If an eligible dependant has more than one parent or guardian who could register them under The Program, then only one of those members may register the dependant.

  3. Note: It is for the members to decide and agree which one of them performs that task.

  4. A member cannot be registered as an eligible dependant under The Program.

  5. A member may elect to register or deregister a dependant at any time.

  6. If a person requests to be removed from The Program, Defence must action that request within a reasonable period of time.

  7. Information about members and their dependants that is collected by The Program is dealt with in accordance with the Privacy Act 1988.

8.9.8 Life of the benefit

  1. Benefits under The Program are only payable on claims submitted within 12 months of the services or products being provided.

  2. This means that the claimant must submit a claim within 12 months of an eligible dependant receiving a service or product in order to be reimbursed under The Program.

8.9.9 Claiming out of pocket expenses

A guide to claiming out of pocket expenses under the program can be found in the ADF Family Health Quick Claim Guide.

See: ADF Family Health Quick Claim Guide

Application to Reservists: Yes, on continuous full-time service.



Forms

Copies of forms are available on the webforms system or through the Defence Service Centre.

  • AD858-1, ADF family health

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Further info

Contact

Defence Service Centre

1800 DEFENCE (1800 333 362)

YourCustomer.Service@defence.gov.au