FOI 26-2617 – Medical Treatment Overseas Program (mtop) MTOP Applications

OFFICIAL/Sensitive//Personal-Privacy

FOI 26-2617 - Document 1

|  APPLICANT |   |   |   |   |   |   | AFFILIATION |   |   |   |   |   |   |   | Exemption Cohort (3, 2, 3 and/or 4)  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
|  No. | Name | Condition | Specialist | Adult | Date Received | Treatment | Approved | Decision Date | Open or Closed | Total Amount Approved | Total Estimated Amount | Comparative Plan? | Refer to Sheet 1 for key | Additional Comments | Medical facility and location  |
|  s22 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |   |
|  s22 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |   |
|  s22 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |   |

OFFICIAL/Sensitive//Personal-Privacy

FOI 26-2617 - Document 2

Australian Government

Department of Health, Disability and Ageing

# FINANCIAL ASSISTANCE TO

# AUSTRALIAN RESIDENTS REQUIRING

# MEDICAL TREATMENT OVERSEAS

# GUIDELINES FOR APPLICANTS

August 2025

These guidelines are intended for distribution to prospective applicants and their Australian treating specialists.

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FOI 26-2617 - Document 2

# INTRODUCTION

The Australian Government may assist persons suffering from a life threatening condition who require overseas medical treatment by way of financial assistance under the Medical Treatment Overseas Program (MTOP) administered by the Department of Health, Disability and Ageing. Financial assistance may be approved by the Minister for Health, or the Minister's Authorised Officer (the Authorised Officer), following advice from a Panel of Departmental Medical Advisers that the medical evidence submitted by or in relation to the applicant meets the medical eligibility criteria set out below.

# 1. ELIGIBILITY CRITERIA

To qualify for assessment under the Program, the applicant must be an Australian citizen or an 'Australian resident', as defined in subsection 3(1) of the Health Insurance Act 1973 (i.e., the applicant must be eligible to receive Medicare benefits), must reside in Australia and must be suffering from a life-threatening condition. The Department of Health, Disability and Ageing will liaise with Services Australia about the applicant's eligibility for Medicare, for the purpose of determining the applicant's eligibility for Australian Government financial assistance to receive medical treatment overseas. To be eligible to receive financial assistance under the Program, the applicant will need to provide evidence addressing each of the four (4) medical eligibility criteria set out below. That evidence will be assessed by Departmental Medical Advisers as to whether those four criteria are met. If the Departmental Medical Advisers do not assess the application as meeting each of these four medical eligibility criteria they will recommend to the Minister, or the Authorised Officer, that financial assistance not be provided to the applicant.

## Medical Eligibility Criteria:

(a) The proposed overseas treatment or an effective alternative treatment must not be available in Australia in time to benefit the applicant

Treatment will be regarded as being 'available in Australia in time' if the capacity, knowledge, skills and/or specialist facilities required to deliver the treatment are available in Australia, or are likely to be available in Australia within a period of time that is likely to be of benefit the applicant.

The MTOP is not available for applicants seeking overseas treatment because of the non-availability of a suitable donor organ in Australia. A decision maker will therefore not consider the availability of donor organs when considering an application to take part in an organ transplant program that is available in Australia.

The MTOP is not available for overseas travel for the purposes of obtaining medical advice or a medical assessment prior to a definitive treatment plan. The application must be for a specific treatment of a specified life-threatening condition.

While a specific treatment may not be available, other treatment options may be available in Australia. It is therefore essential that applicants seeking financial assistance establish that neither the proposed treatment, nor an effective alternative treatment, is available in Australia.

**Note:** Photon therapy is available in Australia and may be an effective treatment for applicants requiring radiotherapy. Applications for Proton Beam Therapy (PBT) must demonstrate that PBT provides a significant improvement in health outcomes compared to

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FOI 26-2617 - Document 2

photon therapy. Applications for PBT must be submitted with comparative proton versus photon plans unless the applicant falls into one of the following patient cohorts:

- Cranio-spinal irradiation in patients aged up to (and including) 25 years
- Brain tumours in patients aged up to (and including) 5 years
- Base of skull chordomas and chondrosarcomas, following maximal safe resection, in patients aged up to (and including) 25 years
- Patients with a diagnosed predisposition syndrome (such as Li Fraumeni syndrome) with increased risk of secondary radiation induced malignancy and aged up to (and including) 25 years

The Australian treating specialist involved in supporting the application should advise of the efforts they have made to confirm that neither the treatment proposed to be obtained overseas nor effective alternative treatments are available in Australia.

Further evidence may also be sought from independent medical experts, the applicant, and/or Australian and overseas treating practitioners and facilities by the Department of Health, Disability and Ageing in the course of assessing the application.

To meet this criterion, the applicant must demonstrate that the proposed overseas treatment is likely to provide a significant improvement in health outcome compared to any alternative treatment available in Australia.

(b) The treatment must be significantly life extending and potentially curative

For this criterion to be met, the applicant must provide evidence that their condition is life-threatening and that the outcome of the proposed treatment offers a significant extension of life expectancy and the prospect of a cure.

This criterion does not require evidence of normal life expectancy after treatment, but the treatment must provide both the prospect of cure and a significant extension of life expectancy.

The proposed treatment should not be merely palliative in nature or simply aimed at providing effective symptom control for the life-threatening condition.

An application must contain evidence, including the results of medical examinations or assessments, which indicate that:

- the condition is life-threatening; and
- the applicant has a realistic prospect of a cure and a significant extension of life expectancy from the proposed treatment.

To assist in the assessment of this criterion, the Australian treating specialist should provide references to published scientific literature demonstrating the benefits from the proposed treatment and its expected outcomes.

(c) There must be a real prospect of success for the applicant

Clinical evidence must be provided to demonstrate that the proposed treatment has a strong probability of success for the individual applicant. This should include medical evidence regarding the stage of the applicant's medical condition, the results of any prior treatment, and any significant co-morbidity.

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FOI 26-2617 - Document 2

The supporting Australian treating specialist should provide information regarding the patient's prognosis without the proposed treatment, with alternative treatments available in Australia (if any), and with the proposed overseas treatment.

(d) The treatment must be accepted by the Australian medical profession as a standard form of treatment for the applicant's condition

The applicant must provide evidence that this treatment is accepted by the Australian medical profession as a standard form of treatment. For example, the applicant's supporting Australian treating specialist could provide position statements published by relevant Australian medical expert groups.

Where relevant, a comparison with alternative treatments should also be provided.

The MTOP has been established to assist patients to gain access to treatments accepted as effective by the Australian medical profession but is not available to support individuals wishing to receive experimental treatments or to participate in a clinical trial.

Generally, the results of clinical trials are published in reputable medical journals before the medical profession in Australia accepts a new therapy as a standard form of treatment. This is because the publication process involves peer review by relevant experts to assess the quality and validity of reports of clinical trials and their suggested results.

In assessing the application, the Department of Health, Disability and Ageing may also seek information or opinion from relevant professional organisations or professional medical experts. A de-identified copy of the application submitted by the applicant may be provided to the craft group.

## Administrative Eligibility:

Applicants will not qualify for an assessment against the four medical eligibility criteria under the Program where:

- the applicant is not eligible for Medicare; or
- the application has not been supported by the applicant's Australian treating specialist; or
- there is no treatment plan presented; or
- the proposed treatment is not for a life-threatening condition; or
- the treatment is palliative in nature and not with curative intent; or
- there is insufficient medical and clinical information presented to undertake an assessment; or
- the application is for participation in a clinical trial or to receive experimental treatment; or
- the applicant has not submitted a proton versus photon comparative plan with the application for Proton Beam Therapy (for...