Part 5: Assessment and treatment of care needs · Web viewWe’ll generally consider that the cost...

Companions to the Lifetime Care and

Support Guidelines

ContentsPart 5: Assessment and treatment of care needs...................................................................................1

Part 6: Reasonable and necessary treatment and care needs.............................................................5

Part 7: Rehabilitation.................................................................................................................................... 9

Part 8: Attendant Care Services...............................................................................................................13

Part 9: Education Support......................................................................................................................... 16

Part 10: Respite........................................................................................................................................... 20

Part 11: Participants living overseas.......................................................................................................22

Part 12: Motor Vehicle Modifications.......................................................................................................24

Part 13: Equipment..................................................................................................................................... 29

Part 14: Home modifications..................................................................................................................... 33

Part 15: Prostheses..................................................................................................................................... 39

Part 16: Voc rehab and training...............................................................................................................41

Part 17: Buying in to the Scheme............................................................................................................44

Part 18: Payments under the Scheme.....................................................................................................46

Part 19: Alternative payments.................................................................................................................. 48

Part 20: Ambulance.................................................................................................................................... 49

Part 21: Dental treatment......................................................................................................................... 51

Part 22: Medical treatment....................................................................................................................... 54

Part 23: Workplace and Education facility modifications....................................................................58

0DRAFT FOR CONSULTATION V0.1


What are the Companions?

The Companions support understanding of the Lifetime Care and Support Guidelines (the Guidelines). The Guidelines are issued under the Motor Accidents (Lifetime Care and Support) Act 2006 and provide information about:

eligibility for the Scheme, and how decisions are made about eligibility how we make decisions services, and requests for services.

The purpose of each Companion is to consolidate and reframe the content of the Guidelines in line with Plain English. By doing this we make the Lifetime Care and Support Guidelines more accessible to our participants and the community. Each Companion is a stand-alone document that complements the corresponding part of the Guidelines.

Document control details

Content Developer and Plain English Author

Karee Gurtman

SME approval Suzanne Lulham, Catherine Bain, Deb McConnell

General Manager approval Don FergusonVersion 0.1Date issued November 2017Date to be reviewed

Part 5: Assessment and treatment of care needs

What is assessment?“Assessment” means:

An assessment of your needs by a service provider, which could lead to a request for us to pay for an item or service;and

Our assessment of your needs, to make a decision whether to approve your request for an item or service.

When a service provider or health professional assesses your needs, they might: complete a report; complete a plan or a request for

services on one of our forms; and/or provide additional information to

accompany a plan or request already submitted to us.

We will then assess your needs and make a decision whether to approve the item or service you are asking us to pay for.

Service providers must use our procedures and approved forms. All of our forms are available on our website. If there isn’t enough information in a request for us to make a decision, we may request that you, a service provider or other person on your behalf provide more information.

We identify your needs through a comprehensive assessment of your strength, abilities, limitations and desired participation goals. During the assessment we consider anything that helps or stops you from achieving your goals. Assessments use objective tools wherever possible and any risks are identified. We then work closely with you, the people close to you and service providers to plan and manage these risks.

Plans and requests for servicesWe’ll help you outline your goals and expected outcomes in your plans and requests. In establishing your goals you, or a service provider on your behalf, should record and address the things that will help, or stop you from, reaching your goals.. Your plan should also explicitly state which services we’ll fund and which ones we won’t to meet your motor accident injury related treatment and care need.


icare lifetime care assesses the treatment and care needs you need because of an injury you sustained from a motor vehicle accident.

icare lifetime care’s funding principles and processThe following principles guide us when we make decisions about your need for services: planning, decision-making and risk

assessment activities are collaborative and this is evident in plans and requests for services

we aim to maximise your independence and community participation

services are flexible and tailored to meet your individual needs

the treatment, item or service is appropriate, benefits you, is value for money and cost effective

the provider is appropriate to meet your needs

the treatment or care need relates to the motor accident injury

you have the right to refuse services.

This is the process for how we make decisions about treatment and care needs: we need to get some information

about your care needs, and the treatment or service you are asking us to pay for;

after we get this information, we make an initial assessment within 10 working days about whether this is “reasonable and necessary” and related to the motor accident;

our decision is written and communicated via a letter to you, called a “certificate”

you have the right to dispute any decision we make about your needs. That’s OK, and we can help you to do this.

Communicating with youEffective communication with you and the people close to you is essential for assessment, planning and delivery of services. We aim to communicate with you in ways that best suit your individual circumstances.

Plans and requests for servicesWe’ll help you outline your goals and expected outcomes in your plans and requests. In establishing your goals you should record and address any potential environmental or personal barriers or facilitators. Your plan should also explicitly state which services we’ll fund and which ones we won’t to meet your motor accident injury related treatment and care need.

Service deliveryOur service delivery involves communicating and cooperating with you, your family and service providers. We aim to maximise your independence and your participation in life roles in the community. You have the right to direct your service delivery to the extent that this is possible or wish to and you have


the right to refuse services, even when others may consider this choice to be unwise.

Assessing your treatment and care needsWe may conduct an assessment of your treatment and care needs if we’ve identified the need or if you or someone on your behalf requests that we pay for an item or service. You can make a request on a form, in writing or verbally to us or a service provider.Service providers must use our procedures and approved forms when conducting assessments and all of our forms are available on our website. If there isn’t enough information in the request to undertake a needs assessment, we may request that you, a service provider or other person on your behalf provide more information.A request for us to make an assessment may include more than one of the following treatment and care needs: medical treatment, including

pharmaceuticals dental treatment rehabilitation ambulance transportation respite care attendant care services aids and appliances (equipment) prostheses education and vocational training home and transport modification

workplace and educational facility modifications.

We may decide to assess more than one request for assessment of treatment and care needs at the same time.We may fund a service provider, such as a case manager, to assist you to access services or request that we fund an item or service.

Reviewing requests‘Review’ means our decision-making process. If we have all the relevant information to make a decision about your treatment and care needs, we’ll make a decision within 10 working days of receiving your request. This does not apply to prostheses and home and transport modifications over $10,000.00. For these we’ll advise you in writing of the status of your request within 20 working days.

We’ll give you a certificate that outlines why we’ve approved or not approved your request. We’ll also provide you with information about the process for resolving disputes about treatment and care needs.

Ongoing assessmentsWe’ll consider any of the following factors when deciding when and how many assessments should be carried out:


the nature and severity of the motor accident injury

whether you’re an interim participant (expect assessments to occur more frequently)

how many requests we’ve received from you

when the motor accident injury occurred

the extent of your treatment and care needs

if your motor accident injury affects your ability to request an item or service

the extent to which the need for multiple assessments can be decreased.

Assessment or medical exams with an external service provider or health professionalWe may request that you undergo an assessment or a medical examination with an external service provider or a

health professional. If you agree we may request them to: complete a report complete a plan or a request for

services on one of our forms provide additional information to

accompany a plan or request that’s already been submitted to us.

If you refuse a reasonable request which results in us being unable to make an assessment, we may not be

able to decide whether the requested treatment or care need benefits you, is appropriate and cost effective.If there’s not enough information because you haven’t undergone an assessment or medical examination, we may not be able to approve a requested treatment or care need. If this happens we’ll write to you to tell you that: we’re unable to make a decision to

approve the treatment or care need the reasons for, and circumstances

of the non-approval of the treatment and care need and

we won’t arrange and pay for services to meet the treatment and care need.

How we review or make a decision about your treatment and care needsA decision means our final determination of what we will fund based on the information from an assessment. In undertaking an assessment, Lifetime Care and our service providers will: consider your views identify your goals, aspirations,

strengths, capacity, circumstances and context

assess how you do things for yourself and how you access the community

assess your risks and safeguards consider assessment and planning

principles


wherever possible, use appropriate standardised objective assessment tools as published on our website.

We may need the following information to help us make a decision about whether to pay for an item or service: answers to questions we or service

providers ask you hospital records treating doctor’s reports and other

medical reports past medical records or school

records other pre accident information or

general medical information and any other information we think is

relevant.

Reasonable and necessary criteria used to determine needsWe use the criteria outlined in Part 6 of the Lifetime Care and Support Guidelines to help us make a decision about whether your treatment and care need is related to your motor accident injury.

Information we need to make a decision about whether an item or service is related to the motor accident injuryWhen we decide whether a treatment or care need is related to the motor accident injury we’ll consider: whether it’s possible to assess the

nature and extent of any injury you

had before the accident, or another injury you had in the accident to determine the treatment and care need solely related to the motor accident

whether a pre-existing or co-existing injury has been made worse by the motor accident injury

whether there are other needs related to the motor accident injury that may be affected if we decide that a need is not related to the motor accident injury

any other information we consider relevant.

Incurred expenses and reimbursementWhere possible, we will assess your needs and make a decision about whether to pay for an item or service needs is done before you pay for the treatment, item or service expense. If you or someone on your behalf pays for an item or service and requests that we reimburse the expense, we may assess the treatment and care needs relating to the motor accident injury outlined in this part and use the criteria in Part 6 to make a decision about whether the expense is reasonable and necessary.

For more information contact icare lifetime care


Part 6: Reasonable and necessary treatment and care needs

What are treatment and care needs?Treatment and care needs are any needs that are connected with: medical treatment (including

pharmaceuticals) rehabilitation ambulance transportation respite care attendant care services aids and appliances (equipment) prostheses education and vocational training home and transport modification workplace and educational facility

modifications

What is reasonable and necessary?We consider treatment, rehabilitation and care services to be ‘reasonable and necessary’ when they benefit you, are appropriate and cost effective.

The treatment, item or service will benefit youWe consider if: you’ve been involved in the planning

of goals and outcomes and you have identified, understood and agreed to them

the proposed treatment, item or service relates to your goals and

makes it easier for you to participate in the community

you prefer the proposed treatment, item or service to others or you have agreed to the request

there is relevant information showing the requested treatment, item or service will benefit you

any risk from providing the treatment, item or service is offset by the expected benefit

you, people close to you, service providers and Lifetime Care have agreed to, assessed, developed and documented a plan to manage any risk

your outcomes will progress or maintain your recovery/management

an adverse outcome or risk occurs if the treatment, item or service isn’t provided

the treatment, item or service or similar or related ones have been provided in the past with positive results or outcomes.

The treatment, item or service is appropriate to your treatment and care needsWhen we apply this we consider if: it’s in line with your goals it’s in line with current clinical

practice, is based on or informed by evidence or in line with clinical guidelines


it’s consistent with your current medical or rehabilitation management

it’s evident that it’s effective it’s currently provided by a similar

service it’s congruent with other services

that are going to be provided to you there are any contraindications other services or provision of

equipment won’t provide an improved outcome

after considering other available services, it’s the most appropriate available

you prefer it or have agreed to it it’s new or innovative, there is

sufficient rationale for offering it and measures exist to quantify its outcomes. We think that there is sufficient rationale for new or innovative treatment only when:

o peer reviewed journal articles or other evidence-based literature shows its effectiveness

o practitioners in the field widely support it

o it’s beyond the early stages of clinical trial

o there is a Medical Benefits Schedule (MBS) item number (for medical treatment, procedures and surgery) and

o you have made an informed choice to accept the risk

associated with the treatment and documented your consent.

The provider is appropriateWhen we apply this we consider if: you have chosen or expressed a

preference for a provider or have agreed to the proposed provider

the provider is qualified and appropriately experienced to provide the service unless you have chosen another provider

the provider is available to meet your treatment and care needs

you can readily access the provider the provider is registered by the

Australian Health Practitioner Regulation Agency if they are a health practitioner as defined in section 5 of the Health Practitioner national Law (NSW) No 86a

the provider is an approved provider under Part 18 of the Lifetime Care and Support Guidelines.

The treatment or care need relates to the motor accident injuryWe consider: the evidence that shows that the

service relates to the injury or injuries sustained in the motor accident

whether pre-existing injuries are exacerbated

time since injury, subsequent injuries and comorbidities.


Considering risk An expense won’t be reasonable and a treatment and care need won’t be reasonable and necessary if: it’s likely to cause you harm it relates to an illegal activity it poses an unacceptable risk to you

or others.

Do you need it?We follow icare lifetime care funding principles to determine the treatment and care you need and we may also refer to other guidelines to help us in this process.

icare lifetime care’s funding principles and processThe following principles guide us when we make decisions about your need for attendant care services: planning, decision-making and risk








This is the process for how we make decisions about your treatment and care: we need to get some information

about your care needs, and the rehabilitation you are asking us to pay for

after we get this information, initial assessments are made within 10 working days


you have a right to dispute any decision we make about your needs. That’s OK, and we can help you to do this.

Other factorsWe’ll assess your treatment and care needs on a case by case basis applying the criteria specified in this part of the Lifetime care and Support Guidelines and any other criteria or information we consider relevant in the circumstances. We may consider other relevant criteria or considerations including your age, ethnic, cultural and linguistic background.

Other guidelinesWe may adopt other publications whether with or without modification or


addition and whether in force at a particular time or from time to time. We use the current versions of the following publications when we assess treatment and care needs: The Neuropsychological assessment

of children and adults with traumatic brain injury: Guidelines for the NSW CTP Scheme and the LTCS Scheme

Guidelines for the prescription of a seated wheelchair or mobility scooter for people with a traumatic brain injury or spinal cord injury

Guidelines for the prescription of a seated wheelchair or mobility scooter for people with a traumatic brain injury or spinal cord injury:

Supplement 1: Wheelchair features – Standing wheelchair

Any additional guidelines we have developed or adopted and published on our website.

What we don’t fundThe things we pay for don’t include treatment and care needs or expenses: for other needs related to the motor

accident injury that are reasonable and necessary in the circumstances but not connected with any treatment and care needs

that are not reasonable and necessary in the circumstances

for an incurred expense that is not reasonable

if the service isn’t within any of the categories of treatment and care needs

for your family members that compensate for economic loss

relating to the motor accident such as lost wages, weekly benefits or other forms of income maintenance or income support

that constitute assistance to keep a business open such as paying for temporary staff to do your job

that relate to items that were lost or damaged in the motor accident

that relate to payments for large capital items such as houses and cars.

We may also consider other factors when we make a decision about whether proposed or incurred expenses are unreasonable or don’t relate to reasonable and necessary treatment and care needs.



Part 7: Rehabilitation

What is rehabilitation?Rehabilitation is the process of enabling

you to work towards independent living. This involves using your physical, mental, social and vocational abilities to participate in all aspects of life. It includes therapies such as physiotherapy, occupational therapy, speech pathology and psychology. It also includes case management services when you need support to participate in rehabilitation or identify, plan and continue participation. Rehabilitation includes documenting plans, requests, reports, case conferences or contact with other professionals treating you.

Health PractitionersA registered health practitioner or an appropriately trained person under their supervision must recommend, direct and provide for your rehabilitation needs. You must request the service before it starts unless it’s urgent or delivered under an existing fee schedule. Your health practitioner should measure any aspects of your health status that may change with

rehabilitation, such as pain, depression, activities of daily living, health-related quality of life and work performance. Your goals relevant to your injury must be developed, and able to be measured in a way that is reliable, valid and flexible.

Concurrent treatmentThis occurs when treatment is provided simultaneously by more than one type of provider or where similar services are provided by one provider type. The services may aim to achieve the same goals but the objectives and treatment approaches may or may not be complementary. We’ll pay for concurrent treatments when: there is a reasonable clinical

justification the treatments are part of a

coordinated plan that we’ve approved

treatment providers ensure treatment provision and goals are closely aligned

there is written information outlining the request for service

treatments by the same type of provider are directed towards different conditions to achieve different treatment goals, such as musculoskeletal physiotherapy and nuerophysiotherapy.

We’ll generally regard using more than one case manager at the same time to be concurrent unless it’s related to a


icare lifetime care will pay for the rehabilitation you need because of an injury you sustained from a motor vehicle accident.

short term need, such as hand over to another case management services provider. Individual and group sessions delivered by the same provider are not considered to be concurrent treatment.

Gym programsWe’ll pay for gym programs when they’re in connection with a rehabilitation program or other exercise program developed in conjunction with a qualified exercise professional, such as a physiotherapist or exercise physiologist. We’ll need to know: any biological, psychological and

social factors that influence your need for gym membership or exercise program as part of your rehabilitation

information from a qualified exercise professional about the proposed program including frequency of attendance

pre or coexisting medical conditions that affect whether the treatment or care need for gym membership is related to the motor accident injury

medical clearance from a relevant treating specialist that you’re able to participate

information about the need for an attendant care worker or support person to facilitate access and ensure safe participation

justification for the proposed intervention, including the relationship to the motor accident and

evidence of consistent participation in a previous exercise therapy or rehab program, or attendance record for the gym or exercise program for subsequent requests.

We’ll also look at the cost of two gyms in your local area as a guide to how much is reasonable for a gym membership in your circumstances. If you have a preference for one gym over the other, you need to show us why we should pay for the preferred gym, including the relationship to the motor accident. If we find that it’s unreasonable we may contribute the cost of the local gym membership towards the membership of the preferred gym and you’re able to fund the difference. We’ll pay for the assistance of an exercise physiologist or personal trainer when: you need specialist assistance that

an attendant care worker is unable to provide

an exercise physiologist or personal trainer is not concurrent treatment.

Do you need it?We follow icare lifetime care funding principles to determine the rehabilitation you need and we may


refer to other guidelines to help us in this process. We’ll also consider if the rehabilitation: is required because of the motor

accident injury is going to be effective and achieve

measurable improvements promotes progress towards your

independence, participation and self-management or maintains function and prevents deterioration and secondary health conditions

Information we need to do this includes:

your needs for rehabilitation in the context of other treatment and services you are receiving

biological, psychological and social factors that influence your health

pre or coexisting medical conditions and how these may impact your rehabilitation needs

how the proposed intervention and treatment process has been justified.









This is the process for how we make decisions about rehabilitation: we need to get some information

about your care needs, and the rehabilitation you are asking us to pay for




What we don’t fundThe things we pay for don’t include rehabilitation or expenses for: a condition that existed before the

motor vehicle accident


assistance to keep a business open such as paying for temporary staff to do your job

services beyond the purpose of the rehabilitation for the motor accident injury

services where the cost is included in the hospital or inpatient rehab bed day fee

costs of telephone calls or internet connection for participants to arrange appointments by phone or email

fees for cancelling an appointment after the first episode of non-attendance, unless the reason for non-attendance is beyond your control

gym or exercise programs that are not prescribed by a qualified exercise professional

gym clothing, towels, fitness/yoga mats and drink bottles.

Other guidelinesWe adopt the Clinical Framework for the Delivery of Health Services in connection with rehabilitation.

Do you have a request that’s not covered by another part of the Guidelines?We’ll apply this part to assess your treatment and care needs. For example, if you ask for driving lessons that are unrelated to the use of a modified

vehicle then we’ll consider funding it under this guideline.



Part 8: Attendant Care ServicesWhat are attendant care services?Attendant care services include personal assistance, nursing, home

maintenance, and domestic services.

Personal assistanceThis includes daily living tasks such as personal hygiene, meal preparation, banking and shopping, taking medication, exercise, using equipment you need for your injury, or planning activities that help you participate in the community, recover from your injury and get from one place to the other.

NursingWe’ll pay for nursing services when you need the specialised skills of a registered nurse.

Home maintenanceThese are routine and seasonal or episodic services that maintain the property you currently live in and include things like cleaning external gutters, window cleaning, and changing light bulbs and smoke alarm batteries.

Domestic ServicesThese are regular and routine tasks like cleaning, gardening, lawn mowing, car washing and swimming pool cleaning for the property you currently live in. We’ll pay for these services to ensure safe and easy access to your home, and as often as we think is reasonable.

Do you need it?We follow icare lifetime care funding principles to determine the attendant care services you need and we may also refer to other guidelines, to help us in this process. We’ll pay for services if they help you with your everyday needs. We’ll also pay for these services if they help you return to work or develop new skills in a safe way that suits your lifestyle and supports independence.

When you’re away from homeIf you’re away from home for an extended period of time or if you’re going on holidays we’ll need to know so that we can make sure your attendant care services continue meeting your needs. We’ll also consider funding any extra attendant care related to your travel because you are away from home and in a different environment. We generally think that a total of 28 calendar days of extra attendant care expenses each year is reasonable. This time can be taken in one break or split into a number of shorter breaks over


icare lifetime care will pay for the attendant care services you need because of an injury you sustained from a motor vehicle accident.

the year. You can also combine the days across 2 years if you want a longer break. .

TravelWhen you can’t travel in economy class because of your motor accident injury, , we’ll generally consider funding the cost difference between economy class travel

and the class of travel you need to meet your needs. We’ll generally consider that the cost difference of one domestic and one international return flight per calendar year is a reasonable frequency..

ChildrenWe’ll pay for attendant care services for children who have a need as a result of a motor accident injury but this will not include babysitting, child care or out-of-school hours care costs.

Are you a carer?If you’re a parent or a caregiver we can support you continue in this role. This could mean helping you travel with your child to take them to and from school.

Alternatives to attendant care servicesSchool holiday programs, child care, community–based groups or community access programs are things that we’ll consider providing as an alternative to

attendant care services as long as they are injury-related, age appropriate and cost effective.





the service is appropriate, benefits you, is value for money andcost effective




This is the process for how we make decisions about attendant care: we need to get some information

about your care needs, and the attendant care services you are asking us to pay for

we assess this information and make a decision within 10 working days


our decision is written and communicated in a letter to you, called a “certificate”


What we don’t fundThe things we pay for don’t include services or expenses: related to an injury that existed

before the accident that are of no clear benefit to you that are unsafe for you or the

attendant care worker

for members of your family or people you live with

that replace parenting or direct caring responsibilities

related to job training or replace your job tasks

when you’re in hospital or inpatient rehabilitation

requiring a qualified tradesperson for upkeep of a farm or farming

activities that are home improvements, such

as renovating or decorating such as direct care or supervision of

family members travel, unless the travel is for a

treatment and rehabilitation service or its to activity that we have paid for

domestic services that are part of a daily bed fee or residential accommodation fee

cleaning products, materials or equipment

waste removal or tip fees holiday expenses such as travel

costs, meals, accommodation, visas or immunisations.

Other guidelinesWe follow the best practice guidelines developed by the Attendant Care Industry Association (ACIA) to decide on the type of attendant care or nursing support to meet your needs.



Part 9: Education Support

What are education support services?If you are a student, educational support services are additional supports that promote independence in your learning and are additional to what you are entitled to under the relevant state or federal legislation.It can include assistance with preschool, childcare (including before and after school care), primary and secondary schools or other education settings such as higher education.Education support services may include assistance with short-term needs such as assisting you to catch up on missed curriculum because of prolonged hospital admission, teacher release time or professional support so that they can modify programs to meet your needs or implement a rehabilitation or special education program. It could also include helping you transition from primary school to high school, support to engage with the curriculum or specific subjects. We also pay for a school learning support officer or attendant care worker’s time for overnight excursions/camps and specialist support services such as

therapists, special education teachers or other professionals when the education service support is delivered with other rehabilitation services.

Do you need it?We follow icare lifetime care funding principles to make a decision about the education support services you need and we may also refer to other guidelines, to help us in this process. We’ll pay for services if they help you with your everyday needs. We’ll also pay for these services if they help you return to school or study or develop new skills in a safe way that suits your lifestyle, supports independence and is based on measurable outcomes.

We take into account your individual needs in the context of other treatment and services provided such as rehabilitation, attendant care services and equipment, the environment that the education supports will be delivered and your ability to perform or be assisted with tasks. These may change when you achieve measurable outcomes, your education program changes, your needs or circumstances change or the service is no longer the most appropriate response to your needs.

We expect that a review of your needs happens where the education support service will be delivered. How long you


icare lifetime care will pay for the education support services you need because of an injury you sustained from a motor vehicle accident.

request the education support for will be considered in the context of your injury-related needs and stage of rehabilitation, e.g. requests may be more frequent as you return to school.

Information we may need from you

We may ask you for any of the following types of information to help us assess your needs: relationship to the motor accident

injury, including nature and severity of injury

your pre accident development and learning history

services that you have accessed, was on the waiting list for, or was assessed as needing prior to the motor accident

pre or coexisting conditions that may also give rise to a need for education and support services

measurable changes in your ability to engage in education and training because of your motor accident injury

relationship to other needs such as rehabilitation and attendant care services

the status or outcomes of any application for assistance through the NSW Department of Education, Association of Independent Schools of NSW or Catholic Education Commission of NSW

reasons for the type and level of education support requested and service provider

TutoringTutoring is a service provided in addition to a school education program and in conjunction with that program providing you with individual support with a specific subject or study skill. Tutoring aims to help you resume your pre-accident level of academic achievement or level consistent with your motor accident injury. We’ll consider paying for it when the service: relates to a specific need for

education support because of the motor accident injury

promotes your independence in the education setting

identified as the most effective approach after we’ve considered what the education facility has already implemented

will help you achieve measurable learning outcomes and goals

complements other education support services and specialist services such as neuropsychology, psychology, speech pathology and occupational therapy.

Along with our funding principles, we’ll consider the following factors when we make a decision about tutoring: evidence of any additional

fatigue/anxiety that you’ve


experienced since your motor accident injury

whether the service is subject specific and linked to the curriculum

it supports the goals and outcomes of your individual learning plan

the content is personalised and delivered one to one or in small groups

sessions are scheduled outside regular class hours

the service provider has knowledge of the curriculum, subject content and current teaching practice

the provider is able to provide outcome measurements/progress reports as required

the service is time limited.









This is the process for how we make decisions about education support services: we need to get some information

about your care needs, and the services you are asking us to pay for




What we don’t fundThe things we pay for don’t include services or expenses: for a condition that existed before a

motor accident or that is not a result of a motor accident

that you accessed, was assessed as needing or was on the waiting list for prior to the motor accident

such as school fees, fees for excursions or school camps, stationery and uniforms


travel that is not related to your treatment or care need, such as travel to and from school

support or services available to all students that are part of the school curriculum

that would be funded by the employer/education provider such as continuing professional development for teachers and other staff

education materials or resources that are not specifically needed by you

tutoring or other programs for you if there is no identified learning support need

for tutoring requests that are not supported by the school or are for tasks that are the responsibility of the parent or guardian, such as supervising homework, accessing the local libraryor preparing school projects.



Part 10: Respite

What are respite services?Respite services are planned and short term services that support and enhance the sustainability of the family unit or usual living arrangements in the household where you live by providing you with a break from usual care arrangements or facilitating and supporting the primary informal relationship between you, the family or your carer.

Do you need it?We follow icare lifetime care funding principles to make a decision about the respite services you need and we may also refer to other guidelines to help us in this process. The services must: be age appropriate consider your needs in relation to

other treatment and services provided, including attendant care and equipment

consider the needs of the family unit or usual living arrangements,

including who you choose to deliver your attendant care services

consider the environment or environments of the delivery of respite services

To help us make a decision, we’ll need information about: the motor accident injury, including

the nature and severity pre or co-existing conditions that

may also give rise to a respite care need

relationships to other treatment and care needs such as attendant care, equipment and home modifications

reasons for the type and level of respite services you request and the service provider.

Alternatives to respite servicesWe’ll consider funding services such as centre-based respite, flexible respite and in some circumstances other programs as alternatives to respite care when they are: age appropriate provide appropriate support assessed as a suitable alternative to

meet your injury-related need designed to support and sustain you

and your usual care arrangements. We may also review your need for attendant care services as an alternative to respite care. If you’d like to request attendant care in an alternative setting on a short term basis, please refer to Part 8 Attendant


icare lifetime care will pay for the respite services you need because of an injury you sustained from a motor vehicle accident.

Care Services when a participant is away from home.

icare lifetime care’s funding principles and processThe following principles guide us when we make decisions about your need for attendant care services:

planning, decision-making and risk assessment activities are collaborative and this is evident in plans and requests for services








about your care needs, and the attendant care services you are asking us to pay for




What we don’t fundThe things we pay for don’t include services or expenses: that existed before the motor

accident injury or that are not a result of a motor accident injury

that are not for short intervals (but respite services may be scheduled at periodic intervals during a 12 month period)

for attendant care or domestic services under Part 8

for holidays as respite services, such as travel, accommodation and activity costs for a holiday

that exceed an injury related need, such as additional costs incurred because you chose a respite option that offers a higher level of support than you need.



Part 11: Participants living overseas

What can we fund if you’re living overseas?Treatment and care needs when you’re living overseas may include a brokerage, case management or other contracted service to assist you with the administration of your services. We may consider special circumstances, outlined in Part 18 of the Guidelines, in relation to non-approved providers to deliver your services. We may also enter an agreement with you to pay expenses to you for a fixed period. We’ll aim to meet your treatment and care needs in a way that is compatible with local service provision in your country of residence but we can only fund the following services that are locally available where you live: medical treatment (including

pharmaceuticals) dental treatment rehabilitation ambulance transportation respite care attendant care services aids and appliances prostheses education and vocational training home and transport modification workplace and educational facility

modifications

We’ll pay in Australian dollars and won’t exceed costs that would be incurred if you were living in Australia.

Do you need it?We follow icare lifetime care funding principles to make a decision about the services you need if you live overseas and we may also refer to other guidelines, to help us in this process. We may waive part or all of our procedures, such as filling in forms, if we can otherwise be satisfied that your need is injury related. If we don’t have enough information we may be unable to make a decision on whether your need is related to the motor accident or the cost is reasonable.











about your care needs, and the services you are asking us to pay for




What we don’t fundThe things we pay for don’t include services or expenses: that are unreasonable when

compared to similar services provided in NSW or Australia

where there is insufficient information about your injury-related need for the item or service

related to relocating to another country, such as visas, travel agent fees or immunisation

related to repatriation, flight or accommodation for your return to Australia

related to medical or allied health professionals travelling to your country of residence to assess or treat you.



Part 12: Motor Vehicle Modifications

What is a motor vehicle modification?These are minor or major changes to your motor vehicle that you need because of an injury you sustained from a motor vehicle accident. Minor modifications are temporary or permanent changes that do not alter the structure of the vehicle or its safety and do not require certification by the licensing authority. These could include a seat belt buckle cover to enable you to travel safely in a vehicle, panoramic mirrors, fish eye mirrors, a spinner knob or an indicator extension lever. Major modifications are permanent changes to the structure of the motor vehicle and require certification by the licensing authority, such as left foot accelerator, mechanical hand controls, wheelchair hoist systems, wheelchair restraining devices or wheelchair access ramps. Major modifications must be prescribed by an occupational therapist that’s qualified in driver assessment.

Electronic hand controls

We follow these procedures when making decisions on electronic or electro-mechanical hand controls: The modification supplier must

provide a written quote A range of industry specialists,

vehicle modifiers and converters should be consulted to provide a range of quotes and options for vehicle modifications – at least two quotes from two different suppliers are required

Requests to fund electro-mechanical hand controls, such as space drive technology, should be preceded by a trial of mechanical hand controls in a suitably modified vehicle or be accompanied by medical evidence establishing an inability to use hand controls. We’ll consider funding electro-mechanical hand controls only if you can’t use mechanical controls.

Insurance, repairs and maintenance of modificationsWe’ll pay for the insurance of the modification, being the difference in comprehensive insurance costs between an unmodified vehicle and a modified vehicle. We’ll maintain and repair an installed modification when it’s: required to maintain the

functionality of the modification limited to normal wear and tear


icare lifetime care will pay for the motor vehicle modification you need because of an injury you sustained from a motor vehicle accident.

not covered under warranty or covered by insurance.

We’ll also maintain and repair it where the cost of the modification has been shared between us and you or the owner of the vehicle and the cost is consistent with our contribution towards the modification.

Replacements

We may replace rather than repair the vehicle modification when: it’s not cost effective to repair the projected life expectancy of the

modification has expired the occupational therapist or

engineer recommends new equipment

the modification no longer meets the participant’s needs.

Modifications to workplace vehiclesWe’ll only consider paying for minor or adaptive modifications to more than one vehicle, which you’ll use at the same time where you reasonably require modifications to enable your return to work and if they don’t form part of the employer’s obligations for reasonable adjustment. For example, we’d consider funding two steering wheel spinner knobs where you required the use of a spinner knob in a private vehicle as well as your employer’s vehicle.

Modifications to a subsequent vehicleWe’ll consider funding major modifications to a motor vehicle every 8 years unless there’s a change in your injury related needs or circumstances which prevent access to the modified vehicle or unless there are some other circumstances that would make the funding reasonable such as: if you use a wheelchair and

previously required modifications for passenger access but now have returned to driving

when the previous vehicle no longer meets your injury related needs due to a change in functional status

if the previous vehicle can’t be repaired and requires replacement.

If the owner of the modified vehicle wants to purchase a replacement vehicle, we’ll consider it reasonable to fund the transfer of the modifications (where not commercially available) to the replacement vehicle wherever possible.

Driver rehabilitation services We’ll pay for the reasonable costs of driving rehabilitation designed by an occupational therapist qualified in driver assessment, where the need is related to the motor accident injury and the specific goal is for you to learn to use the modifications. This includes lessons from a qualified driving instructor in a suitably modified vehicle


with dual controls. If you have medical clearance and you are medically fit to drive or at least to attend an off and on road assessment of your driving performance we’ll consider paying for driving lessons for modified vehicles. We’ll also pay for: a medical examiner to certify your

fitness to drive an off and on road assessment

conducted by a driver trained occupational therapist

lessons recommended by a driver trained occupational therapist

minor modifications to a vehicle that you own or have access to so that you can have driver practice hours.

AgreementsWe may need you to enter an agreement that describes the conditions of use, maintenance insurance and ownership of the vehicle. It may include one or more of the following: subsequent ownership changes of ownership frequency of future modifications maintenance and repairs to the

vehicle’s adaptations or modifications

ongoing costs related to the modification such as insurance

the requirement to repay the reasonable contribution to us if the vehicle is sold.

Do you need it?We follow icare lifetime care funding principles to determine the equipment you need and we may also refer to other guidelines to help us in this process. We’ll pay for a motor vehicle modification if you: have a physical, sensory and/or

cognitive disability as a result of the motor accident injury which prevents you from safely driving or travelling as a passenger

have reached a level of maximum recovery and stability in your functional ability to drive or be transported as a passenger in a vehicle

require modifications so that you can get in and out of the vehicle, be transported safely in a wheelchair or to transport a wheelchair

own or have access to a motor vehicle or planning to purchase a vehicle to modify

intend to be a driver of the modified vehicle and will obtain or retain your licence.

We’ll collaborate with you to make a decision about your needs in connection to the vehicle modification. We’ll consider your individual needs and social and physical environment, whether your needs for vehicle modifications are likely to change and identify and recommend the most


appropriate and cost effective option. We’ll also need to know: how often you need to access the

vehicle, especially if the vehicle is shared between family members

the modification suitability and cost of a vehicle owned or used by you prior to the motor accident injury, including age, condition and ownership

that the vehicle being modified is in good condition and will remain roadworthy and registrable

suitability of the modification and cost of a new vehicle (purchased or yet to be purchased) following the motor accident injury, including age, condition and intended ownership

that there is a documented agreement between you and the vehicle owner, if it’s not owned by you, that they consent to the modification and agree to your ongoing use of the vehicle

that the recommended modification has been successfully trialled

the costs of modifications (over the expected life of the vehicle) compared with alternative transport options.

Before we make a decision an occupational therapist experienced in vehicle modifications must make a recommendation. You must provide two quotes for the recommended modifications, or an explanation

regarding why only one quote is available.If you intend to be the driver of the modified vehicle you must provide a medical certificate by a treating medical practitioner providing evidence that you are medically cleared to return to driving and you have been assessed by a driver trained occupational therapist, certified by the appropriate licensing authority.

icare lifetime care’s funding principles and processThe following principles guide us when we make decisions about your need for motor vehicle modifications: planning, decision-making and risk









This is the process for how we make decisions about vehicle modifications: we need to get some information

about your care needs, and the equipment you are asking us to pay for




What we don’t fundThe things we pay for don’t include motor vehicle modifications or expenses: that are major modifications to more

than one vehicle at the same time relating to conditions before the

motor accident that provide no functional benefit to

you over a period of time such as if you only use the modified vehicle infrequently and other means of transport are more cost effective or appropriate

intended for you but you are not medically cleared and licensed to drive

if you have been assessed as unsafe to drive

that are part of a universal service obligation or reasonable adjustment such as a road or footpath

that compensate for the lack of public transport in your local area

that do not comply with the requirements of a registration body, current national medical standards or the applicable Australian Standards and design rules

related to the purchase of a vehicle associated with motor vehicle

ownership including licensing, registration, compulsory third party insurance and comprehensive insurance

to convert the vehicle back to its standard configuration once major modifications have been installed

that form part of the supplier’s or vehicle modifier’s warranty or insurance policy such as repairs

loss, theft or damage to the motor vehicle or its modifications

maintenance and repairs that all vehicle owners are expected on a vehicle to keep them in safe working order

day to day running costs such as oil, petrol, parking fees or tolls

maintenance or repairs that are for aesthetic reasons or to add value to a vehicle

cancellation fees for non-attendance at driving lessons as part of driving rehabilitation


driving lessons if you are charged with a driving offence such as drink driving or speeding during your driving rehabilitation

driving rehabilitation for any period of time when your licence is suspended or cancelled

initial lessons for a new learner driver where the need is not related to the motor accident injury and there are no modifications to the vehicle.



Part 13: Equipment

What is equipment?Equipment is an aid, appliance or

assistive technology that increases or maintains your independence, community participation, mobility and good health. It can aid communication, relieve pain or discomfort and also ensure your safety, including that of your family, carers or attendant care workers. Wheelchairs, commodes, pressure care cushions and shower chairs are common equipment items.

Personal computers, internet access, tablets, and smart phonesIf you’re enrolled in distance education, unable to access the computing facilities of your education institution and don’t own or have access to computer equipment we’ll pay for it if: it assists you return to work,

including working remotely until you can access your workplace

it’s required for a vocational retraining program where the goal of the program has been confirmed by a Work Options Plan and we support this goal

it will increase your functional independence in your instrumental activities of daily living such as shopping and money management where you live in a remote location, have a severe physical impairment or have some other motor accident injury related condition that inhibits your access to the community.

you’re enrolled in distance education, or school or tertiary education that is able to provide remote learning

you’re unable to access your educational institution, including the computer facilities of the educational institution and

you don’t own or have access to suitable computer equipment only where the school or educational facility does not have a ‘bring your own device’ or similar in place.

We’ll also pay for short term internet access if you’re: a hospital inpatient temporarily

unable to access your workplace participating in a short-term therapy

program delivered via the internet or skype or

participating in a short-term return to work program.

Tablets and smart phones are generally not considered equipment. However, we may pay for it when you need the device for a rehabilitation program


icare lifetime care will pay for the equipment you need because of an injury you sustained from a motor vehicle accident.

where the item is used to measure an increase in independence or improve injury–related communication deficits.

Exercise and fitnessWe’ll pay for exercise and fitness equipment if they’re related to goals documented in your plan and you’ve been regularly using similar hire or loan equipment.

Recreation and leisureWe’ll pay for leisure or recreation equipment if it assists you return to or start a leisure activity that’s right for you.

General household and personal itemsWe generally don’t pay for household appliances but we’ll pay for beds, mattresses, and domestic goods such as washing machines if the need for a specific type is directly related to the injury.

AgreementsWe may need you to enter an agreement that describes the conditions of use, maintenance insurance and ownership of the equipment.

Ordering equipmentHealth professionals or a team of professionals with recognised qualifications have the skills and

knowledge to prescribe equipment by filling out an equipment request form or ordering through one of our suppliers. We provide the following guidelines on our website: ‘Professional Criteria for Prescribers’ ‘Guidelines for levels of attendant

care for people with spinal cord injury’

‘Summary of the Guidelines for the prescription of a seated wheelchair or mobility scooter for people with a traumatic brain injury or spinal cord injury’.

Hiring equipmentIt may be better to hire equipment if your medical condition or circumstances are likely to change or your living arrangements are unknown and it’s not possible to confirm whether or not the equipment will function in your home. Hiring equipment may also suit you if the equipment is needed for a short time or if the prescriber wants to trial the equipment with you before purchase.

Maintaining and repairing equipmentWe’ll repair equipment when: the need is due to normal wear and

tear recommended by the manufacturer it needs adjustment because it

doesn’t fit.


We’ll pay for equipment maintenance and repair when it’s not covered under warranty or insurance and the cost would be the same for a replacement or modification.

Replacing equipmentWe’ll replace your equipment when: your needs have changed and a

modification is not possible replacing it is due to normal use

over time and repairing it is not possible.

Do you need it?We follow icare lifetime care funding principles to determine the equipment you need and we may also refer to other

guidelines to help us in this process. We’ll pay for equipment if: you can show that the item is

related to an injury you sustained in the motor accident

the equipment has been successfully trialled and you are able to safely use the equipment in your environment

you outline how it’s implemented and any training, acquittal and review requirements

you have written support from your education facility if the equipment supports return or entry into an educational activity.

If you’d like specific equipment which is more expensive than an equivalent item we may contribute to the cost. We’ll need two quotes if the equipment costs more than $2,000.00 and we don’t have an existing agreement with the supplier.









This is the process for how we make decisions about equipment: we need to get some information

about your care needs, and the


equipment you are asking us to pay for




If your needs haven’t changed and you request a replacement because of usual wear and tear over time, and it’s the same as the one previously prescribed, you don’t need to fill in an equipment request form.

What we don’t fundThe things we pay for don’t include equipment or expenses: that are not cost effective related to neglect, abuse, misuse or

loss related to continence aids, supplies

or other consumables where you are an inpatient, or the bed fee includes these costs

for general household and personal items which would normally be replaced by you – even if we’ve funded the original purchase

when the repair or replacement is covered under warranty or insurance

that don’t comply with Australian Standards or not registered with the Therapeutic Goods Administration

that replace or upgrade an item when the existing item meets the need

related to the additional cost of software, hardware or peripherals where this is your personal preference and it’s not required to maximise your independence

related to the additional cost of software upgrades where this is your personal preference, and it’s not required to ensure that your computer remains serviceable or maximises your independence in computer use

related to cellular data or the cost of connecting the device to the internet

related to an upgrade or replacement of the device

related to applications other than those prescribed to meet an injury related need

related to equipment that’s available for use in another setting (such as a gym) that is appropriate for you to access

related to equipment that is used by you solely in other environments such as a physiotherapist’s rooms

related to the purchase of equipment when we consider hire is more appropriate, such as no definite living arrangements.


Part 14: Home

modifications

What are home modifications?If the motor accident injury restricts or stops you from accessing your home or being able to use your home’s standard fittings we’ll pay for a home modification. These can be minor or major. Minor modifications are straightforward and have a cost limit of $25,000.00. They don’t change the external structure of your home and could be a temporary internal or external ramping, simple rails, shower screen removal or entrance widening. Major home modifications are complex as they change the internal or external structure of your home, involve many tradespeople, require a detailed plan or Council approval or cost over $25,000. This could include things like adding or removing walls, adding a wet area or shower or erecting a new structure.

What we need from youWe’ll need the following circumstances to exist before we can pay for a home modification:

You and the home owner have agreed in writing to the home modification.

The body corporate or other relevant authority has given approval in writing.

Alternative options, such as relocation, have been considered and excluded.

The scale and cost is the most feasible option when considering the benefits.

There are no prohibitive structural constraints, e.g. surrounding terrain and condition of the home.

Do you need it?We follow icare lifetime care funding principles to make decisions about the home modifications you need. We’ll consider who owns the home, the expected length of stay at the home and whether the home modification is the most cost effective option. We may ask an occupational therapist to complete a home assessment. We may also need to identify anything in your environment that is a barrier and options to overcome these barriers such as providing equipment, non-structural changes to the home and relocation. We’ll also consider clinical reasons for the home modification and the best option for you.

Information we need from you


icare lifetime care will pay for the home modifications you need because of an injury you sustained from a motor vehicle accident.

To assess your need related to the home modification we’ll need to know: how you enter and exit the home which areas of the home you access

daily project plans, including the cost and

extent of the home modification that the home modification meets

relevant Australian Standards required consents e.g. a landlord,

body corporate or local Council how equipment such as wheelchairs

effect how you function in your environment

whether there may be any future changes or improvements to your mobility.

Do you own your own home?If your need is related to the motor accident injury we’ll pay for a home modification to your primary home, if you intend to remain living there for at least 5 years and relocating is not the best option for you.

Do you have a second home?We’ll modify your second home when it’s not your usual place of residence but you spend a significant amount of time there because of shared parenting arrangements or it’s a holiday home. We’ll also pay for ramps, rails, doorway widening and minor bathroom modifications to provide you with basic access. We’ll need to know if we’ve paid for any previous home modifications,

the amount of time you expect to spend there and how modifying the second home would benefit you.

Interim accommodationIf major modifications are taking place to your home and you can’t access it or live there, we’ll pay for short term accommodation, as long as it’s no more than 9 months and it’s the most cost effective option to meet your needs. We’ll also pay for family members who will be displaced because of the building process and if it’s your first major home modification.

Are you renting?We’ll pay for modifications to a rental property if: your name (or your parent or legal

guardian, if you’re a child) is on the lease

the owner agrees in writing you intend to stay there for the

foreseeable future and if the cost does not exceed

$12,000.00 multiplied by the number of years in the term of the lease (e.g. $24,000.00 for 2 year lease).

We may also pay for the cost of returning your rental property to its former state if the owner requests it and it’s related to the modifications we previously approved.


Relocating if the home can’t be modifiedWe’ll pay for your relocation if: you’re being discharged from

hospital for the first time since the accident or

your needs have significantly changed

we’ve decided that the home is unable to be modified and you have to purchase another home or enter a lease for a new home

it’s the best option in the circumstances.

If you meet these requirements and you or a member of your family whom you live with buys a new home or relocates to a rental property, we may pay for related costs such as: real estate agent fees legal fees stamp duty cleaning costs furniture removal building or strata reports and pest

inspection costs related to finding a rental

property or home to buy if you are unable to do this

fees for breaking a tenancy agreement

furniture removal an assessment and report to find a

home by someone that we’ve approved, such as a building modifications occupational therapist (BMOT).

We may need a current building, strata or pest report and advice and recommendation from a BMOT and building modification project manager’s (BMPM) assessment of the property to help us make a decision.

Purchasing another homeWe expect that you’ll choose a home that doesn’t need a lot of changes to meet your needs. We may pay for a BMOT or BMPM to look at the home you’re purchasing to advise you if the home will meet your needs. We’ll also pay up to $85,000.00 for: accessible entry to and exit from the

home a bathroom and toilet a bedroom a laundry and kitchen if you do your

laundry and prepare your own meals

Off the planIf you’re thinking about building a new home we expect that you’ll choose a home design that doesn’t need a lot of modifications to meet your needs. We’ll pay for a BMOT or BMPM to review the design and advise you on whether the home will meet your needs. We’ll pay for the difference between the standard cost of building the home and any additional costs incurred for: accessible entry to and exit from the

home a bathroom and toilet a bedroom


a laundry and kitchen if you do your laundry and prepare your own meals.

Room temperature control equipmentIf you’re unable to self-regulate your body temperature because of the motor accident injury and this probably won’t change or the lack of room temperature control causes secondary care complications, we’ll pay for room temperature control equipment. To help us make this decision we’ll consider the main areas of the house that you’ll access and the structure and layout of your home. We’ll also consider clinical evidence related to self-regulating your body temperature. If you have a spinal cord injury we’ll need to know the level of the spinal cord lesion.

Energy costs

We’ll contribute up to 35 % of your energy bill from the date of installation or the start of using room temperature control equipment when: we’ve funded the room temperature

control equipment or agree that you need the existing room temperature control equipment

there’s evidence that the energy costs can be directly related to the temperature control equipment to meet your needs

you’ve applied for or are receiving rebates such as the NSW medical energy rebate for NSW residents.

We’ll also contribute to the costs related to servicing, maintenance and repair of the equipment.

Environmental control systems and unitsWe’ll pay for equipment and modifications that increase your independence in daily activities. This could be equipment such as openers, intercoms, emergency call alerts or light and telephone controls that work with an environmental control unit or ‘electronic aids to daily living’ to improve access and independence in the home. To help us make a decision about this we may need information on: the expected increase in your

independence a prescription by an Occupational

Therapist results of any trials of the system availability of a back-up system consideration of cost effective

alternatives cost, set up, ongoing support and

maintenance of the system and unit.

Repairs and maintenanceWe’ll pay for repairs and maintenance when they’re essential for your access or safety or for any wear and tear to a home modification. We’ll also pay a proportion of the original costs paid if


we didn’t fully pay for the original home modification.

AgreementsWe may enter an agreement with you that specifies conditions of use, maintenance, insurance and ownership. It may include: changes of ownership or sale of the

home frequency of future home

modifications maintenance and repairs ongoing costs such as insurance any requirement to repay the

reasonable contribution amount to us if the home is sold.

If these situations don’t apply then we may consider the request on a case by case basis.









This is the process for how we make decisions about home modifications: we need to get some information

about your needs, and the modifications you are asking us to pay for




What we don’t fundThe things we pay for don’t include: repairs or modifications that you

need because of a pre-existing condition

illegal structures repairs for conditions that existed

before the accident, such as termite damage or concrete cancer


in ground or aboveground pools, spas or aqua therapy facilities

upgrades of any materials required for the home modification

items or labour not included in the final contract for modifications we have agreed to

normal household items such as furniture or whitegoods, surge protectors, towel rails, fans, lights, hot water services, security doors and windows

anything that adds value to an existing property and isn’t related to the motor accident injury

loss of value to the home because of a home modification

loss of value or costs associated with removal of a minor or major home modification

another home modification, if we have paid for one in the past 5 years, unless your personal circumstances have unexpectedly changed

costs for removing a major home modification from you or your family’s home

interim accommodation when there was an accommodation issue before the injury, the need is not because of the injury or you have declined other accommodation options

costs related to the end of a tenancy such as advertising costs, steam cleaning carpets or cleaning a property at the end of the tenancy

repairs to your home

any home modifications that we haven’t approved

the cost of more than one strata, building or pest inspection report

internet costs for researching suitable properties

body corporate/strata fees council or water rates modifying a new home build

because the design does not meet your needs

changes to plans that are made at no cost to you

any standard cost related to the finishings of a new home, such as bathroom tiles, taps, flooring

modifications that are above the standard cost

standard costs related to building a new home, such as council fees, external consultant or engineer fees

repairs and maintenance of environmental control systems and units due to wear and tear or not funded by us.



Part 15: Prostheses

What is a prosthesis?Prosthesis is an artificial substitute for a missing body part, such as a leg, used for functional or cosmetic reasons or both. It includes any associated componentry and relates to an external prosthesis or orthosis. It doesn’t include a surgically implanted prosthesis.

Who is a provider?Providers are accredited medical prescribers, amputee clinics or limb manufacturers. Maintenance and repairWe’ll repair and maintain your prosthesis: because of normal wear and tear because of routine maintenance that

the manufacturer recommends or if it’s to meet industry standards

if a provider or providers that are accredited by NSW Health, Enable NSW or an equivalent body if you live interstate, completes the prescription and supply.

Recreational activity

We’ll pay for an additional prosthesis for recreational use if you are likely to engage in the activity on a regular and ongoing basis. For example, we may fund specialised limbs for a sporting activity where involvement in the activity can be demonstrated by sporting club membership and evidence of attendance and participation.

Do you need it?We follow icare lifetime care funding principles to determine the equipment you need and we may also refer to other guidelines to help us in this process. We’ll pay for prostheses when: the need has arisen through

amputation of a limb as a result of the motor accident injury

the prosthesis promotes functional independence, self-management or cosmetic improvement

the provider is accredited by ‘enable NSW’, or an equivalent body if you live interstate

the prescription, clinic services and manufacturing services are provided by a person who is accredited by ‘enable NSW’ or an equivalent body if you live interstate.

icare lifetime care’s funding principles and processThe following principles guide us when we make decisions about your need for prostheses:


icare lifetime care will pay for the prostheses you need because of an injury you sustained from a motor vehicle accident.

planning, decision-making and risk assessment activities are collaborative and this is evident in plans and requests for services







This is the process for how we make decisions about prostheses: we need to get some information

about your care needs, and the prosthesis you are asking us to pay for




What we don’t fundThe things we pay for don’t include prostheses or expenses: for repair and replacement of a

prosthesis if its repair or replacement is required because of neglect or misuse.

Prosthesis that do not comply with Australian Standards (if applicable), or if it’s not registered with the Therapeutic Goods Administration (if applicable).



Part 16: Voc rehab and training

What is vocational rehabilitation and training?Vocational rehabilitation is when

combined and coordinated services restore or try to restore you to the maximum level of employment or other work related activity you are capable of or wish to achieve. Work related activity is an activity that enables you to acquire skills to improve your ability to get work in the future. Vocational training is formal training that maintains or develops job related and technical skills.

Payments to help you start workingWe may make payments for incidental expenses not exceeding $1,000.00 to help you start employment when: it addresses an immediate or short

term barrier that directly prevents you from starting work or accepting an offer of employment

you have received a written job offer the need arises before you start

work and receive the first payment from your employer

it’s not provided or to be provided by the employer.

We’ll make one or more payments for incidental expenses only when the total amount is no more than $1,000.00 over the course of your participation in the Lifetime Care and Support Scheme.

Do you need it?We follow icare lifetime care funding principles to determine the vocational rehabilitation and training you need and we may also refer to other guidelines to help us in this process. We’ll pay for vocational rehabilitation and training if a suitably qualified rehabilitation provider identifies a need and is supported by evidence that the need relates to your motor accident injury and there are clearly defined, specific, measurable, achievable, realistic and time-based vocational goals. You must make a request in writing, outlining how the rehabilitation and training will promote progress towards your vocational goals and aim to return you to your original employment with your pre-injury employer. If you’re unable to regain employment with your pre-injury employer you must outline how the rehabilitation and training will help you gain employment with a different employer. When we make a decision about paying for your vocational rehabilitation and training we’ll consider:


icare lifetime care will pay for the vocational rehabilitation and training you need because of an injury you sustained from a motor vehicle accident.

your pre-accident life roles, career and intended study plans

your ability to engage in vocational rehabilitation and / or training as a result of the motor accident

whether you and your medical/rehabilitation team agree with the choice of vocational goal

existing vocational rehabilitation services or training that you can access

your capacity to achieve a sustainable employment outcome

identifiable labour market opportunities on completion of training

your willingness to commit to the vocational training

alternatives to training previous vocational training

expenses paid for by us the cost and duration of any

requested vocational training the cost and duration of any travel

that may be required to attend vocational training.

icare lifetime care’s funding principles and processThe following principles guide us when we make decisions about your need for vocational rehabilitation and training: planning, decision-making and risk








This is the process for how we make decisions about vocational rehabilitation and training: we need to get some information

about your care needs, and the service you’re asking us to pay for




What we don’t fundThe things we pay for don’t include vocational rehabilitation and training or expenses: of no clear benefit to you


that address needs that are unrelated to the motor accident injury

for someone else and not you you can access or are required to

access under other state or federal legislation

assistance to keep a business open, such as paying for temporary staff to do your job

standard furniture and other items associated with your place of employment or work health safety requirements

everyday living expenses associated with employment, such as travel to and from place of employment, clothing/uniforms or lunches

phone calls, photocopying, stationery, meals at training venues and all other expenses associated with training

costs of training courses that you had enrolled in or commenced prior to the injury

training that’s related to maintaining an existing qualification, licence, registration or accreditation once you have obtained the qualification, licence, registration or accreditation

training that’s part of induction, ongoing skill maintenance or development that’s your or your employer’s responsibility

training associated with voluntary career changes or personal development

ongoing training costs where the training or educational institution determines that you are guilty of serious academic misconduct

ongoing training costs where we and the educational institution decide that you have failed to maintain satisfactory academic progress

that an employer has a legal obligation to provide, such as personal protective equipment or orientation training

that an employer will provide to the employee at no cost to the employee such as standard issue uniform

household and everyday living costs income support.



Part 17: Buying in to the Scheme

Buying in to the SchemeWe’ll calculate the amount required to provide services to meet your

treatment, rehabilitation and care needs for the rest of your life. Buying in to the scheme is voluntary and is subject to an agreement between us and you or your guardian.

How do I apply?You or someone on your behalf can make an application. The application must be in writing there must be enough information to allow us to decide if your motor accident injury meets our eligibility criteria and you would have been eligible to enter the Scheme had your motor accident occurred after 1 October 2006 for children and 1 October 2007 for adults.

What if I don’t meet the eligibility criteria?We may decline your application if your injury does not meet the eligibility

criteria but you can dispute this. Part 1 of the Guidelines has more information on this.

How we calculate the cost to buy inWe need information about your previous and current treatment, rehabilitation and care needs so that we can calculate how much it would cost for you to buy in to the Scheme. Information includes: your current age and age at time of

the injury the nature and severity of the injury current assessment of your

functional status such as FIM™, WeeFIM®, the Care and Needs Scale (CANS) and American Spinal Injury Association (ASIA) scale for spinal cord injury

objective assessments of your previous and current treatment, rehabilitation and care needs; and

the nature, frequency and duration of services utilised to meet these treatment, rehabilitation and care needs, including any variations in care needs during periods of transition.

We may arrange for your assessment so that we can obtain this information and we’ll pay for the reasonable and necessary cost of the assessments. We’ll also provide you with a copy of the assessment.

What the buy-in amount includes


If you sustained a motor accident injury before 1 October 2006 (for children) and 1 October 2007 (for adults) and your injury meets the eligibility criteria, you can buy in to become a lifetime participant in the Lifetime Care and Support

The amount we decide for you to buy into the Lifetime Care and Support Scheme includes: the full lifetime expenses in

providing for your reasonable and necessary treatment, rehabilitation and care needs related to the motor accident injury

the administrative and associated costs we incur in managing you as a lifetime participant in the Scheme.

We’ll notify you of the amount required to buy inWe’ll notify you in writing of the amount required for you to buy in, including information on how we calculated the buy in amount. We’ll receive the buy in amount upfront and pay the amount into the Lifetime Care and Support Authority Fund (the Fund) in full once received. We’ll consider security over real property instead of a cash payment only after the liquidation of personal assets to meet the buy-in amount.

Buy in as a lifetime participantAfter you’ve paid the buy in amount to us in full, we’ll write to you confirming that you have become a lifetime participant and that the buy in amount has been paid into the Fund. We can’t ask for additional payments from you once the buy in amount has been paid.

Once you have become a lifetime participant, you have the same obligations and entitlements as any other lifetime participant in the Scheme.



Part 18: Payments under the Scheme

Approved attendant care providersAn approved attendant care provider is an organisation that holds the Attendant Care Industry Association’s endorsed certification to the Attendant Care Industry Standard (or current equivalent). We require that only approved attendant care providers provide services to you unless we have made a different agreement with you. If you live outside NSW or the ACT we’ll consider paying non-approved providers to deliver attendant care services.

Approved providers for rehabilitation services (Case Management)An approved case manager is an individual or organisation that we approve through a submission and evaluation process. Case Managers must work with a mentor for a probationary period until they can demonstrate that they can meet our expectations. Our expectations for case

management service providers can be found on our website.If you live outside NSW and ACT we’ll consider paying non-approved providers to deliver case management services.

Major home, workplace and educational facility modificationsA major home, workplace or educational facility modification refers to any building modification that alters the internal or external structure of a residence, is complex, involves multiple tradespeople and requires a detailed plan or Council approval and costs over $25,000.00. Reasonable and necessary services for or in connection with major home, workplace and educational facility modifications include the services of an occupational therapist and building modifications project manager. We undertake a competitive selection process to appoint approved providers who are building modification occupational therapists (BMOT) and building modification project managers (BMPM).Only approved BMOTs can provide occupational services connected with the major modifications and only approved BMPMs can provide project management services connected to the major modifications. However this doesn’t apply if you live outside Australia.


icare lifetime care will undertake a competitive selection process to appoint approved providers of attendant care services within NSW and ACT.

Special circumstancesWe’ll consider whether any special circumstances exist to justify paying a non-approved provider where an approved provider provides a service. This could be things like your geographic location or cultural or religious reasons, but they may not necessarily result in us approving

payments to a non-approved provider - we’ll consider this case by case.We’ll need a written request from the person or organisation seeking to deliver services. The request must include: the reason(s) why none of the

approved providers are appropriate their suitability to provide services

to you ,such as their relevant experience and training

the circumstances said to justify approval of that person or organisation to provide services to the participant

your agreement with that provider any other information we think is

relevant.If approval is granted to pay a non-approved provider we’ll set out the duration of the approval and the rates of payment in our written agreement to fund the services.

What we don’t fund

The things we pay for don’t include expenses for services delivered before a provider has obtained approval.



Part 19: Alternative payments

Does the alternative expenditure benefit you?We’ll consider making a contribution to alternative expenditure where the treatment, care, support or service outcome is at least equally beneficial as if we had paid for the expenses to meet your treatment and care needs.

Do we agree with the alternative expenditure?We won’t make a contribution to alternative expenditure unless you or your parent or legal guardian agrees that the alternative expenditure can meet your treatment and care need.

When someone other than you (the participant) or Lifetime Care make or contribute to alternative expenditure, we’ll need that person to agree to our contribution.

Is it in your best interests?If you lack capacity to agree with this decision, we won’t contribute to

alternative expenditure unless we are satisfied that it’s in your best interests.

Applying for alternative expenditureThis part applies to our assessment of treatment and care needs that are made on or after the start of the Motor Accidents (Lifetime Care and Support) Ammendment Act 2014.For more information contact icare lifetime care


icare lifetime care will contribute to alternative and cost effective ways to meet your treatment and care needs because of an injury you sustained from a motor vehicle accident.

Part 20: Ambulance

Do you need it?We follow icare lifetime care funding principles to determine if you need ambulance transportation and we may also refer to other guidelines to help us in this process. We’ll pay for ambulance transportation if: we don’t otherwise fund it and it’s

required because of the motor accident injury

you need it to access, enter or be positioned in a vehicle and the physical assistance required is greater than what a taxi driver, attendant care worker or family member would provide

it’s for receiving medical or hospital services related to the motor accident injury, or for receiving other services to meet your needs

there are no other alternatives and an ambulance is the only suitable transport for you.

We’ll also consider the following factors: your needs for ambulance

transportation in relation to other treatment and services provided, such as medical treatment and surgery

the circumstances where you need the ambulance - is it between hospitals, from a hospital to your residence after a stay in hospital as an inpatient, or for other medical treatment or therapy services?

if other services , such as vehicle modifications, have been provided instead of ambulance transportation

how long you will need the ambulance transportation.

To help us make a decision about whether we’ll pay for your ambulance transportation, we’ll need information: from a medical practitioner or health

professional as to the need for ambulance transportation compared with other alternatives

on any pre or co-existing medical conditions that may impact on your needs for or in connection with ambulance transportation

about whether you need behavioural management supervision

about whether a family member or attendant care worker is available to provide assistance.

We’ll assess your need for ambulance transportation on request and prior to service delivery. When you make a request you must use an itemised quotation.

icare lifetime care’s funding principles and process


icare lifetime care will pay for the ambulance transportation you need because of an injury you sustained from a motor vehicle accident.

The following principles guide us when we make decisions about your need for attendant care services: planning, decision-making and risk








This is the process for how we make decisions about ambulance transportation: we need to get some information

about your care needs, and the service you are asking us to pay for

after we get this information, initial assessments are made within 10 working days;


you have a right to dispute any decision we make about your needs.

That’s OK, and we can help you to do this.

What we don’t fundThe things we pay for don’t include ambulance transportation or expenses: provided under an existing fee

agreement that are attendance-only charges that are active ‘waiting time’ for an

outpatient driver service upon request by the hospital or facility unless there is a clinical need for you to be actively managed or supervised and an attendant care worker or family member is not present. If this is the case, we’ll only pay active waiting time for the time the outpatient driver has provided active supervision and assistance.



Part 21: Dental treatment

Routine dental treatmentWe’ll pay for routine dental treatment only when treatment is: a direct result of the motor accident

injury, such as severe traumatic brain injury affecting your ability to brush your teeth

required in addition to the level of pre-injury routine dental treatment, such as oral spasticity requiring more frequent dental treatment by a dental practitioner

required to ensure that other forms of dental treatment can be provided, such as a general anaesthetic to treat dental cavities if you have a traumatic brain injury.

DenturesIf you required dentures prior to the motor vehicle accident, we won’t replace them if they were lost or damaged in the motor accident, in hospital or inpatient rehabilitation unless: there’s a direct impact on other

accident-related dental treatment if the dentures weren’t replaced at the same time; and

there’s evidence of direct trauma to the mouth from the accident.

Do you need it?

We follow icare lifetime care funding principles to determine the dental treatment you need and we may also refer to other guidelines to help us in this process. We’ll pay for dental treatment if it’s: required as a direct result of the

motor accident injury related to or caused by side effects

of medications for the motor accident injury and there is supporting information from a medical or dental practitioner to show this

required because of failure to maintain dental health due to the treatment you required because of the motor accident , such as an extended stay in an intensive care unit

in accordance with accepted dental practice

provided by a dental practitioner or other specialist such as an oral and maxillofacial surgeon, registered with the Australian health Practitioner Regulation Agency (AHPRA) or other appropriate professional body if the participant resides outside Australia

intended to restore your dentition to a level that is consistent with your pre-injury standard of dental care.

To help us decide if you need the dental treatment we’ll consider your injury related needs and their impact on your


ability to perform or be assisted with dental hygiene tasks. We’ll also need: information relating to the motor

vehicle accident to establish if dental

injuries occurred through direct trauma to the mouth or facial injuries

information from a medical practitioner as to the likely cause of the presenting dental needs, if you have pre or co-existing medical conditions that may impact on your needs for or in connection with dental treatment

information from any or all dentists where you received treatment prior to your injury

a fully itemised account or quotation from a registered practitioner

an outline of the goals of the proposed treatment

information about your injury related needs and the ability to perform or be assisted with any recommended dental hygiene that the treatment may require.

We may need a second opinion or quote in circumstances where the relationship to the motor accident injury is unclear or we think that the dental treatment is complex or extensive. You must request the dental treatment before the

treatment starts unless it’s an emergency or otherwise urgent.









This is the process for how we make decisions about dental treatment: we need to get some information

about your care needs, and the dental treatment you are asking us to pay for





What we don’t fundThe things we pay for don’t include dental treatment or expenses: solely for aesthetic purposes, such

as teeth whitening that are of no clear benefit to you

that are repeat treatment because of your lack of dental hygiene, unless the reason for treatment is assessed as related to the motor accident injury, such as cognitive and behavioural issues associated with traumatic brain injury

inconsistent with your pre-injury standard of dental care unless the reason for treatment is assessed as being exacerbated or aggravated by the motor accident injury

where there’s no published evidence relating to its safety or effectiveness

associated with non-attendance, unless the reason for non-attendance is beyond your control

standard household expenses associated with dental care such as toothbrushes, toothpaste, dental floss and mouthwash.



Part 22: Medical treatment

Which medical treatment will we fund?Services connected to medical treatment which we’ll pay for include: surgical treatment pharmaceuticals diagnostic tests such as imaging

services inpatient or outpatient treatment

provided by hospital medical treatment, reports, case

conferences or contact with other professionals treating you

assisted fertility treatment and treatment for chronic pain.

Which pharmaceuticals will we fund?We’ll consider: prescription pharmaceuticals over the counter medications prescribed vitamins and

supplements, including health products such as fibre laxatives or probiotics

topical skin creams such as sorbolene

other items such as consumable preparation solutions for a medical procedure.

We’ll consider bandages, dressings and other wound care items and consumable items for continence needs as either pharmaceuticals or equipment.

Assisted fertility treatmentWe’ll consider paying for assisted fertility treatment when: the need arises from the motor

accident injury a suitably qualified fertility medical

specialist makes the referral a suitably qualified fertility medical

specialist has prescribed the most appropriate fertility treatment for you and your partner.

We’ll also consider the following connected treatments: fertility medication, ovulation

induction or assisted insemination in-vitro fertilisation (IVF) treatment assisted ejaculation or obtaining

sperm by other means such as testicular aspiration

egg and sperm storage – the length of time we’ll pay for storage depends on individual circumstances and the advice of the fertility medical specialist

obtaining donor eggs or sperm, including retrieval and storage, in circumstances where you are unable


icare lifetime care will pay for the medical treatment, including pharmaceuticals you need because of an injury you sustained from a motor vehicle accident.

to produce viable eggs or sperm because of the motor accident injury

fertility counselling only as an inclusive part of the assisted fertility intervention for you and your partner

all other forms of assisted fertility or assisted reproductive technology treatment

a reasonable number of IVF treatments per pregnancy attempt in line with usual practice. We’ll consider up to 5 stimulated cycles per pregnancy attempt. If you require more than 5 stimulated cycles we’ll consider the recommendation of the fertility medical specialist to help us decide whether we’ll fund further treatments.

We’ll pay for both you and your partner to receive assisted fertility treatment when it’s your (the participant’s) fertility status that’s affected by the motor accident injury.We’ll also need the following information to help us make a decision: information about the relationship

between your need for fertility treatment and the motor accident injury

the likely permanence of your compromised fertility status

the nature and extent of the treatment that you and your partner will need

the anticipated outcome and success rate of the assisted fertility treatment

information about any other treatment or services that may impact on the proposed treatment

any other relevant information relating to you or your partner’s fertility status.

Do you need it?We follow icare lifetime care funding principles to determine the medical treatment you need and we may also refer to other guidelines to help us in this process. We’ll pay for medical treatment if you need it because of the motor accident injury and it’s provided by a medical practitioner who is registered and appropriately qualified. To help us decide if you need the medical treatment, we’ll consider your injury related needs and their impact. We’ll also need: information relating to the medical

treatment that has an item number in the Medical Benefits Schedule (MBS)

information about pre or co-existing medical conditions

information from a medical practitioner as to the likely cause of the presenting medical treatment – if you have pre or co-existing medical conditions that may impact on your needs for or in connection


with medical treatment or pharmaceuticals

clinical assessments and reports justification for the proposed

treatment, including the relationship to the motor accident

justification for the treatment process, including any associated medical treatment as part of an overall plan.

Who can prescribe treatment?An appropriate specialist or medical practitioner registered with the Australian Health Practitioner regulation Agency (AHPRA) or other appropriate professional body (if you live outside Australia) must prescribe the medical treatment.

Payment codes

The medical practitioner or specialist is to provide medical services using the Australian Medical Association (AMA) item numbers, where there is a corresponding MBS number.

Prior approvalYou must request the treatment prior to when it starts, unless it’s urgent or delivered under an existing fee schedule.

To help us make decisions about whether you need pharmaceuticals, the

appropriate medical practitioner registered with AHPRA, or other appropriate body (if you live outside Australia) must prescribe them. We may request your treating medical practitioner to provide a list of pharmaceuticals related to the motor accident injury before we are able to assess your needs for or in connection with pharmaceuticals. Your treatment and care needs in connection with medical treatment must be made in consultation with you and the medical practitioner and take into account your individual needs in the context of other treatment and services provided.










This is the process for how we make decisions about medical treatment: we need to get some information

about your care needs, and the treatment you are asking us to pay for




What we don’t fundThe things we pay for don’t include medical treatment or expenses: that form part of the bed day fee in

a hospital or inpatient rehabilitation facility

for personal care or grooming, such as toilet paper, shampoo or other items

standard items that you can purchase from a pharmacy such as cosmetics, food and beverages

sunscreen, unless prescribed for scar management

related to contraceptive prescriptions

that are illegal pharmaceuticals associated with medico-legal reports

or any medical reports we haven’t requested

incurred while receiving inpatient or outpatient medical treatment such as food, laundry, newspapers, magazines, phone line rental and phone calls

not in accordance with the MBS explanations, definitions, rules and conditions for services that medical practitioners provide unless we have specified otherwise

without a MBS code where there is no published

evidence relating to its safety or effectiveness

for non-attendance fees where you failed to attend an appointment unless the MBS states otherwise or if the reason for the non-attendance is beyond your control

for a member of your family unless they or your partner are the recipient of assisted fertility treatment

that is of no clear benefit to you for surrogacy, whether commercial

or altruistic for assisted fertility intervention to

address the fertility needs of your


partner if these are not the result of the motor accident injury

that is experimental or not consistent with intervention offered to the general community

for counselling for your partner which is not inclusive of the assisted fertility treatment program

for membership of fertility support/self-help groups for you or your partner

that is not consistent with the guidelines of the assisted fertility treatment facility that you or your partner are attending

that is inconsistent with relevant State or Commonwealth legislation

for any assisted fertility treatment that is elective, or for medical conditions not related to the motor accident injury, such as pre-implantation genetic diagnosis

in relation to raising a child associated with the pregnancy and

birth of the baby conceived through assisted fertility treatment that are not related to the motor accident injury, such as obstetrician, hospital, midwife and/or other birthing costs.



Part 23: Workplace and Education facility modifications

Workplace modifications

We’ll pay for workplace modifications when: the long term impact of your motor

accident injury prevents you from performing your duties within the existing workplace environment

there’s an employer who has confirmed in writing that they’ll provide permanent employment for you

the workplace modification is the most cost effective means for enabling you to return to work and all other alternatives have been considered

a workplace assessment or work options plan has been conducted and we’ve agreed to support the work goal.

Educational facility modificationsCosts for modifications to educational facilities are the primary responsibility of the education facility. We’ll pay for an education facility modification when:

there’s no other funding source and the modifications wouldn’t be provided under any legislation or scheme

the long term impact of your accident injury prevents you from learning within the existing education facility

it’s the most cost effective means for enabling you to participate in the education activity and all other options have been considered

for adult learners, the education program has been identified through a work options plan and we’ve agreed to support the work goal.

Repairs and maintenanceWe may fund the cost of repairs and maintenance for modifications: that are essential for your access or

safety proportionate to the original costs

paid, where we didn’t fully fund the original modification, such as where an employer or property owner also contributed to the original cost of the modification.

Do you need it?We follow icare lifetime care funding principles to determine the workplace and education facility modifications you need and we may also refer to other guidelines to help us in this process. We’ll consider if you need it when:


icare lifetime care will pay for the workplace and education facility modifications you need because of an injury you sustained from a motor vehicle

we’ve confirmed that the proposed modifications are not available under another scheme or legislation, including any reasonable adjustments an employer or education provider may make

a suitably qualified occupational therapist has recommended the

modifications to meet your injury-related need in a workplace or education facility modifications report

the employer or education provider and the building owner (if different) both agree in writing to the modifications.

For workplace modifications we’ll consider the following factors: any reasonable adjustments an

employer may be obliged to make under disability discrimination legislation and whether modifications could be funded partly or wholly under another scheme or another funder.

We’ll also need the following information: your entry and exit from the

workplace your access to all necessary areas of

the workplace the cost and extent of the

modifications when considered in relation to the likely benefit to the participant and alternative employment options.

For educational facility modifications, we’ll consider: your ability to participate in

educational activities as well as access to other facilities such as bathrooms

whether the modifications could be funded partly or wholly by the education provider

We also need information on: the length of time you’re likely to

remain in the education facility reasonable adjustments available to

timetable and class allocation, e.g. conducting your classes on ground floor rooms

your accessibility to all necessary areas of the facility

the cost and extent of the modifications when considered in relation to the likely benefit to you and alternative options for education

To help us decide if you need the workplace or education facility modification, we’ll consider: the physical and social environment

of the workplace or education facility your physical, cognitive and

behavioural impairments, such as impairments to:

o mobility, including wheelchair type

o arm and/or hand functiono thermo-regulationo bladder and bowel functiono cognitiono behaviour


whether any future improvement or change in the above factors is likely

the effects of equipment, including wheelchairs on your ability to function within your work or education environment.

We’ll also need the following information: your safety and that of the

attendant care workers and other employees or students

the ownership of the property

any required consents from other parties such as a landlord, body corporate or local Council.

icare lifetime care’s funding principles and processThe following principles guide us when we make decisions about your need for workplace and education facility modifications: planning, decision-making and risk








This is the process for how we make decisions about dental treatment: we need to get some information

about your care needs, and the modification you are asking us to pay for




What we don’t fundThe things we pay for don’t include modifications or expenses: for any workplace or education

facility that constitute, are likely to constitute or will result in an illegal structure - an illegal structure is one that is contrary to relevant building and construction codes or local council planning guidelines, statutes and/or laws

that haven’t been approved by us


where the owner, body corporate or other responsible authority has not given permission for the modifications and such permission is required

required as a result of a condition that existed before the motor vehicle accident or that is not because of the motor vehicle accident

that provide no clear injury-related benefit to the participant

intended to add value to an existing workplace or education facility and are not related to the participant’s motor accident injury

related to upgrades of any materials required for workplace or education facility modifications

removal of modifications from a workplace or education facility

related to any loss of value of any property resulting from any modifications to or removal of modifications from the property

items that are normal workplace, educational or household items (such as furniture or whitegoods, smoke alarms, surge protectors, towel rails, fans, lights, hot water services, security doors and windows)

items not directly related to your need arising from your motor accident injury

where we’ve funded substantial modifications in the past 5 years

modifications that may be considered an education provider’s obligation as a type of reasonable adjustment under relevant disability discrimination legislation

repairs and maintenance as a result of normal wear and tear (such as replacement of bathroom fittings/fixtures), for the upkeep of a workplace or education facility

related to repairs and maintenance when you are no longer attending the workplace or education facility.



Part 5: Assessment and treatment of care needs · Web viewWe’ll generally consider that the cost...

Documents

Transcript of Part 5: Assessment and treatment of care needs · Web viewWe’ll generally consider that the cost...