icare Lifetime Care
We pay for treatment, rehabilitation and care services for participants in the Lifetime Care and Support Scheme. Services must be ‘reasonable and necessary’ and related to the participant’s motor accident injury.
All services should be pre-approved before they are provided.
Treatment, rehabilitation and care services can include things like:
- medical treatment including pharmaceuticals;
- dental treatment;
- rehabilitation services;
- ambulance journeys;
- attendant care and respite services;
- domestic assistance;
- aids and appliances;
- educational and vocational training;
- home, vehicle and workplace modifications; and
- a range of other things.
Service providers should refer to the Lifetime Care and Support Guidelines when requesting services.
Once services have been approved, you should be given a certificate (or a purchase order) by the participant's icare lifetime care coordinator or case manager. This will detail the services that have been approved. If there are services that haven’t been approved, the reasons will be provided on the certificate.
icare Dust Diseases Care
We will consider paying for:
- doctor's visits and medication, including home-based oxygen and nebulisers;
- ambulance services to transport the worker to a doctor or hospital because of their dust disease;
- treatment for their dust disease in a hospital or nursing home, or in a palliative care or rehabilitation centre;
- therapeutic treatments like exercise and massage;
- respite care (out of home) or rehabilitation centre admissions;
- wheelchairs and other mobility aids — like walking frames or motorised scooters;
- therapeutic needs — like reclining chairs, beds, pressure relief cushions, and shower chairs;
- the cost of travelling to attend their medical appointment;
- hand rails for easy access to the bath and shower; and
- access ramps to your client's house if your client uses a wheelchair or scooter.
We do not pay for:
- treatment or medical costs that are related to another disease or condition;
- payment of the Federal Government Accommodation Bond to enter a nursing home;
- cataract surgery, spectacles and other seeing aids;
- food (including organic food), vitamins or dietary supplements (unless prescribed as part of a treatment regime); or
- medical treatment or medicines received while visiting or living overseas.
If you or your client are unsure of whether we have or will approve payment for a service, please contact us on (02) 8223 6600.
Services our schemes will pay for
What does 'reasonable and necessary' mean?
Services requested must meet all of the following criteria to be considered ‘reasonable and necessary’:
- Benefit to the participant — how the service will help with the participant’s goals for participation in their life and community (for example, going to physiotherapy helps the participant’s ability to propel their wheelchair to get around their community);
- Appropriateness of service — whether the service is right for the participant’s injury (for example, what evidence is there that hydrotherapy is the most effective treatment for their injury and goals? What alternatives have been considered/ruled out? How will it fit in with their other services?);
- Appropriateness of provider — whether the service provider is right for the participant and their injury (for example, is the service provider qualified and experienced in their type of injury, and if possible located near their home);
- Cost-effectiveness — whether the service is the most cost-effective option to meet the participant’s needs (for example, how will a specialised piece of equipment reduce the need for attendant care); and
- Injury-related — how the service relates to the injury sustained in the motor accident (for example, the need for an X-ray is due to the participant’s motor accident injury, not due to another injury/condition they already had before the accident, unless there is evidence it has been made worse by the accident).
There are certain things we can’t pay for. Please refer to our ‘reasonable and necessary’ information sheet for further details.
What does 'reasonably necessary' mean?
The criteria for determining whether services are reasonably necessary include:
- the actual or potential effectiveness of the treatment,
- the appropriateness of the treatment,
- the extent to which other alternative treatments are available and the effectiveness of alternate treatment,
- the cost of the treatment, and
- the extent to which the treatment is considered by medical experts to be appropriate and effective.
If the treatment is considered reasonably necessary, the need for the treatment must also arise as a result of the dust disease.