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Agreed minimum benchmarks for motor vehicle accidents

Who is covered by a NIIS for motor vehicle accidents?

At a minimum, jurisdictions should have eligibility rules which include people who suffer the following catastrophic traumatic injuries in motor vehicle accidents:

  1. Spinal cord injury — based on evidence of a permanent neurological deficit (principally paraplegia and quadriplegia).
  2. Traumatic brain injury — based on evidence of a significant brain injury which results in permanent impairments of cognitive, physical and/or psychosocial functions. A defined period of post traumatic amnesia plus a Functional Independence Measure (FIM)1 at five or less, or two points less than the age appropriate norm (or equivalent where other assessment tools are used), would be required.
  3. Multiple amputations of the upper and/or lower extremities or single amputations involving forequarter amputation or shoulder disarticulation, hindquarter amputation, hip disarticulation or “short” transfemoral amputation involving the loss of 65% or more of the length of the femur.
  4. Burns — full thickness burns greater than 40 per cent of the total body surface area (or greater than 30 per cent in children under 16 years) or full thickness burns to the hands face or genital area, or inhalation burns causing long term respiratory impairment, plus a FIM score at five or less, or two points less than the age norm (or equivalent where other assessment tools are used).
  5. Permanent traumatic blindness, based on the legal definition of blindness.

What is the scope of motor vehicle accidents for the first stage of the NIIS?

Each jurisdiction’s NIIS should cover injuries which arise from accidents which:

  • involve at least one registerable vehicle.
  • occur on a public road or other locations where registered vehicles are commonly driven including driveways and car parks, and areas adjacent to roads such as nature strips, footpaths and other road related areas.
  • are the result of the driving of the vehicle, the vehicle running out of control, action taking to avoid a collision with the vehicle, or a collision with the vehicle while it was stationary, and includes injuries to pedestrians and cyclists injured as a result of such incidents.

Jurisdictions may provide a broader scope if they desire.

For avoidance of doubt the NIIS need not as part of the first stage cover:

  • Unregistered vehicles on private property such as farm vehicles.
  • Unregisterable vehicles such as motor cross bikes, quad bikes, trikes, off‑road or racing vehicles.
  • Bicycles.
  • Other modes of transport (trains, trams, waterborne craft).
  • Injuries arising from organised motor sports.
  • Injuries arising from acts of terrorism involving the use of a motor vehicle.

Which jurisdiction’s NIIS should provide cover?

  • At a minimum each jurisdiction’s NIIS will cover people who are catastrophically injured in motor vehicle accidents which occur in that jurisdiction. Jurisdictions may, if they wish, provide broader coverage extending beyond their jurisdiction.
  • State and Territory NIIS schemes will establish arrangements to purchase care and support services from each other when a scheme participant resides in a different jurisdiction to that which assumes funding responsibility.
  • A review will be undertaken every 5 years to assess the extent to which State and Territory NIIS schemes face differential (net) financial burdens in relation to liability for services provided to non‑residents.
  • In all cases the jurisdiction assuming financial responsibility should retain the right to seek recovery from the CTP insurer of an interstate registered vehicle.

Should there be any exclusions?

The minimum benchmark is that exclusions be limited to persons who:

  • have received a common law compensation payment in respect of their care and support needs resulting from the motor vehicle accident;
  • have an existing catastrophic injury; or
  • are already a participant of the NDIS in respect of the costs of care and support already being provided by the NDIS.

What are the entitlements?

A minimum level of entitlement in each jurisdiction’s NIIS will include reasonable and necessary needs for eligible persons for the following services to the extent that they arise from the motor vehicle accident:

  • medical treatment (including pharmaceutical)
  • dental treatment
  • rehabilitation
  • ambulance transportation
  • respite care
  • attendant care services
  • domestic assistance
  • aids and appliances
  • artificial members, eyes and teeth
  • education and vocational training
  • home and transport modification.

An individual jurisdiction’s NIIS may provide a broader range of services, and may also provide capacity for self‑managed funding by participants where appropriate.

Entitlements will only be provided within the Commonwealth of Australia.

Reasonable and necessary supports:

  1. are designed to support the individual to achieve their goals and maximise their independence;
  2. support the individual’s capacity to undertake activities of daily living to enable them to participate in the community and/or employment;
  3. are effective, and evidence informed;
  4. are value for money;
  5. reflect community expectations, including what is realistic to expect from the individual, families and carers; and
  6. are best provided through a NIIS and are not more appropriately provided through other systems of service delivery and support, including services that are offered by mainstream agencies as a part of its universal service obligation to all citizens.

In determining what is reasonable and necessary the following factors should be considered:

  1. Benefit to the participant — to progress or maintain the participant’s recovery, management and participation.
  2. Appropriateness — services provided are consistent with the participant’s current medical or rehabilitation needs, are consistent with current clinical practices and are congruent with other services provided to the participant.
  3. Appropriateness of the provider — service providers are qualified, readily accessible and appropriate given the participant’s age, ethnicity and other characteristics.
  4. Cost effectiveness of the services — the benefits and expected outcomes outweigh the costs, the cost is comparable to those of other providers, no other services would achieve comparable outcomes and alternatives to purchasing equipment or undertaking modifications have been considered.
  5. That the services provided relate to needs arising from the injury sustained in the motor vehicle accident.

Consistent reporting standards

That each Scheme agree to collect information in regard to the following items and report under a consistent definitional framework:

  1. The number of entrants to each scheme and their characteristics (age/gender/location of service provision — i.e. metro/regional/rural);
  2. The classification of injuries of entrants — Spinal injuries (including level of lesion), head injuries (moderate + severe), other severe injuries;
  3. The average cost of support of scheme entrants (overall and by the agreed injury classification);
  4. The average cost of care in each jurisdiction (to understand variations in the cost of attendant care and monitor trends); and
  5. The amount of care per claim overall and by injury classification.

1 The FIM is a basic indicator of severit
y of functional limitation that uses a seven point ordinal scale for each of 18 activities of daily living. The scale provides for the classification of individuals by their ability to carry out an activity independently, versus their need for assistance from another person or a device. If help is needed the scale assesses the degree of that need.