APPLICATION FORM
APPLICATION FORM FOR
APPLYING TO THE AGED CARE PRICING
COMMISSIONER FOR ACCOMMODATION
PRICES THAT ARE HIGHER THAN THE
MAXIMUM AMOUNT DETERMINED BY THE
MINISTER
Contents
Information about this application
1
1.
Background information
2
2.
Proposed Price and Cost of Supply Considerations
3
3.
Annexure A – Checklist
7
Information about this application
This application form is an approved form for the purposes of an application for a higher than maximum amount of
accommodation payment as determined by the Minister. The Minister has made a determination that the maximum
amount that a provider may charge a care recipient without approval from the Aged Care Pricing Commissioner is
$550,000 as a Refundable Accommodation Deposit or its equivalent. Providers entering into arrangements with
care recipients on or after 1 July 2014 will need to make an application to the Commissioner if they intend to charge
an amount greater than $550,000 or its equivalent. Approval is not required for arrangements with residents who
entered care before 1 July 2014. However, to provide future pricing certainty for providers, it is strongly
recommended that any provider seeking to charge a Refundable Accommodation Deposit of greater than $550,000
or its equivalent in the future should make an application to the Commissioner from 31 January 2014.
All information provided for the purposes of an application will be held confidentially by the Aged Care
Pricing Commissioner, and will not be shared with any other person or agency.
This application form is not to be completed by providers seeking approval to charge Extra Service fees.
That is a separate application process. While applicants may include particular care and services as justification
for an accommodation price for the purposes of this application (provided that such care and services are not
specified in the Quality of Care Principles 1997), applicants cannot seek to charge Extra Service fees for the same
care and services.
Please refer to the Application Guide when completing this application form. The Application Guide has been
developed by the Commissioner to assist applicants and it must be utilised in completing the form. If any further
guidance is required on requirements for completing this application form, please contact the Office of the Aged
Care Pricing Commissioner on 1300 550 970 or acpcenquiries@acpc.gov.au
Once completed, this application form should be emailed to acpcapplications@acpc.gov.au Attachments may
also be submitted electronically, or mailed in hard copy to the Office of the Aged Care Pricing Commissioner,
Locked Bag 3000, Woden ACT 2605. Any such attachments should be referred to in the covering email.
The application form is drafted in three sections. Parts 1 and 2 are mandatory and seek background information
(Part 1) as well as factors supporting the proposed price for which you seek approval and costs of accommodation
(Part 2). Annexure A – Checklist is included to assist applicants in addressing the criteria that the Commissioner is
required to consider. In this section, applicants may confirm that the information requested has been supplied in
other parts of the application form, or may provide the information in the tables at Annexure A.
The Commissioner invites you to submit material in support of your application in ways that are most convenient to
you. For example, you may choose to provide a written narrative or business case to support your application, and
you may also wish to include building and design specifications and plans which highlight the accommodation.
However, you must ensure your application addresses the requirements in Annexure A – Checklist and that
sufficient cost information, including WACC, EBITDA, ROI or IRR, are included at Tables 2.1 and 2.2.
It is necessary that your claim is supported by evidence that indicates the proposed accommodation payment is
justified. While the Commissioner will not be unduly prescriptive about the form in which information is supplied, a
consistent approach to the assessment of these applications will be applied. As provided for under subsection 52G4(3) of the Aged Care Act 1997 the Commissioner will seek further information where applicants have not provided
sufficient detail or evidence to support their claim. It is therefore in the applicant’s best interests to provide
comprehensive material with independent evidence wherever possible.
Please note that while this form may be used for multiple accommodation groups within a facility, applicants seeking
approval in relation to an accommodation payment that is higher than the maximum amount at multiple facilities are
required to submit forms for each facility. Guidance on accommodation groups for the purpose of this application is
provided in Section 1.8 of the Application Guide. Details of the assessment of applications, the application process
and review and appeal rights are contained in Sections 1.4 – 1.7 of the Application Guide.
Applicants are reminded that giving false or misleading information is a serious offence. Further
information may be sought during the assessment if the Commissioner decides it is warranted.
1
1.
Background information
In this section of the application, applicants must provide general information regarding the organisation seeking
price approval, the facility to be assessed and contact details of a person to contact for the application.
Table 1: Background Information
Components
Information
Click in fields below to enter text and values.
(i)
Provider and facility details
Name of Approved Provider
Approved Provider ID number
Service ID number
(NAPS or Residential Aged Care Service ID
number, if existing service)
Name of facility
(service name, including proposed if known)
Address of facility
Street number
Street name
Street type
e.g. Place, Avenue, etc.
Suburb/Town
State
Select State
Postcode
Name of contact person (for this application)
Contact telephone number (include area code)
Email address
(ii)
Application details
1. State whether the application relates to rooms or parts of rooms in:



Choose an item
An existing facility; or
A proposed new facility; or
A proposed refurbished facility.
2. If the application relates to rooms or parts of rooms in a proposed new
facility or a proposed refurbished facility, state the anticipated completion
date for the construction or refurbishment.
3. State whether any other critical dates apply in respect of this application and
what the critical date applies to.
4. Provide any additional care or service costs (other than care and services
specified in the Quality of Care Principles 1997) including Extra Service
fees that are not included in the proposed accommodation price, and
the services offered for those costs. Where the application is for multiple
accommodation groups, please indicate care/services for each group, if
different.
2
2.
Proposed Price and Cost of Supply Considerations
2.1
Proposed Price Considerations
Table 2.1 – Proposed Price Considerations invites applicants to include, by way of narrative or business case,
their considerations supporting the proposed price. Information may be included in the table at 2.1 (provided that
this section does not exceed approximately 2000 words), or submitted along with this application form in the form of
narrative or business case. Applicants are welcome to include information both in Table 2.1 and additional
information as an attachment, if required. Such plans and photographs will obviously support applications for a
proposed price, and will further enable applications to be considered in a timely manner.
The following information is required to be included:

Floor plans and photographs. Floor plans should be sufficient to identify rooms in the accommodation
group, room size and access to common areas. Photographs are not required for every room in the
accommodation group, but should be sufficient to identify the quality, condition and amenity of rooms, and
should be representative of the standard of rooms in the group. These should be provided for each
accommodation group in the application.

The weighted average cost of capital (WACC) at the facility level, or at the enterprise level where this is
most relevant. Alternatively, should measures such as Internal Rate of Return (IRR), Return On Investment
(ROI), Earnings before Interest, Taxes, Depreciation and Amortisation (EBITDA) be more relevant indices,
please supply one of these measures at Table 2.1 (ii).

For applications in respect of existing facilities, please provide the historical bond price for rooms in the
accommodation group over the last 12 months. These should be provided for each accommodation group
in the application at Table 2.1 (iv) or as an attachment.
While there are no other prescriptive requirements, general guidance on information that may be included at Table
2.1 is at Section 2.1 of the Application Guide. Please read this section of the Application Guide carefully before
completing Table 2.1. You should include here any information relevant to the support of your proposed price that is
not otherwise provided in this application, including any additional matters that you consider to be factors in setting
your proposed price at this level, and costs that cannot be readily attributed or capitalised to the particular
accommodation group (such as holding costs, start-up costs, fees and charges related to statutory requirements for
a development, and attributable corporate overheads). You may wish to include reference to accommodation or
design features of the particular accommodation or of the service, where these features are relevant to the person
in the room.
Applications cannot include, as part of their justification for a proposed price, the cost of care and services which
are specified care and services under the Quality of Care Principles 1997. This includes maintenance costs.
Applicants may attach to this application form and refer to those items that support the proposed price, such as land
and/or building valuations conducted within the last 3 years by a qualified valuer who is a member of the Australian
Property Institute, or a contract of sale, or an estimate of land acquisition costs; or an estimate based on the
historical costs convention; or an insured value, or another market-based value (such as the fair value of land and
buildings determined by reference to recent market transactions).
If your application is in respect of more than one accommodation group (which is required if it relates to multiple
possible room configurations), please ensure your narrative supports prices in all groups. Where your application is
for more than one accommodation group, you should, for the second and any subsequent accommodation group,
also complete and submit the Form for Additional Groups, which includes duplicates of Tables 2.2, A.1 and A.2.
3
Table 2.1: Proposed Price Considerations
(i)
Please provide supporting narrative in the text box below, or indicate whether such information has been
provided as an attachment. If information exceeds the limits of this text box, please provide additional
information in an attachment.
Click in field below to enter text.
(ii)
Cost of capital OR level of investment
Click in field below to enter text and values.
Please provide the Weighted Average Cost of Capital (WACC) and identify whether it
is a ‘facility’ or ‘enterprise’ level of WACC. Where IRR, ROI or EBITDA are more
relevant measures, please provide details using one of these measures.
(iii)
Land and building valuation (where relevant)
Click in fields below to enter text and values.
Land valuation (evidence to be attached)
Building valuation (evidence to be attached)
(iv)
Historical Bond Price – Existing facilities
Click in field below to enter values.
For existing facilities, please provide the historical bond
price for room(s) in the accommodation group(s) over the
last 12 months.
Accommodation
Group
Historical
Bond Price
Date
4
2.2
Cost of Supply Considerations
Table 2.2 – Cost of Supply Considerations requires applicants to provide information relating to components of
the cost of accommodation supply that support the proposed price.
It is not envisaged that these cost of supply components comprise all elements of the cost of accommodation
supply, but are components that are key elements of the cost.
The cost of supply components may include (where applicable), but are not limited to, those matters set out at
Table 2.2 – Cost of Supply Considerations.
Please note that applicants are not required to address all matters indicated. Where applicants consider that cost
factors are relevant considerations in respect of a proposed price, these should be included. In addition, any major
cost of supply factor that is not included at Table 2.2 may be included by the applicant under “Other cost of supply
components as applicable”.
The matters in Annexure A – Checklist must be addressed, whether by:


using the tables provided at Annexure A; or
providing information in Part 2, by a building design/specification plan, photographs, or in a narrative or
business case.
Applicants may attach to this application form and refer in this section, where these items are relevant to the cost of
supply and support the proposed price, a quote or estimate of cost for construction of a new facility, or
refurbishment of an existing facility.
Guidance on costs of supply (where relevant) is provided at Section 2.2 of the Application Guide. Acceptable
evidence is further outlined at Appendix A to the Application Guide. The Commissioner will also consider as one
indication the median house price by locality in the assessment of applications. This information is not required to
be supplied by the applicant.
Where a proposed new facility or proposed refurbished facility is in the pre-construction or refurbishment stage,
applicants are able to provide an estimate of the cost of acquiring land (if relevant), estimates of construction and
other costs, and supporting material such as a marketing plan or other information relating to quality, condition and
amenity supporting the proposed price for groups of rooms. These estimates must be accompanied by the evidence
referred to in Appendix A and will be subject to verification at Stage 4 of the assessment process. If there is
significant variance in cost or in amenity, the applicant can make a fresh application to the Commissioner at the
time of verification, or at any time prior to verification, provided that 4 months has passed since the original decision.
5
Table 2.2: Cost of Supply Considerations
(i)
Title and number of rooms
Click in fields below to enter text and values.
Title of accommodation group
Number of rooms or parts of rooms in accommodation group
Number of rooms in whole facility
Proposed price per room as Refundable Accommodation Deposit ($)
(ii)
Cost of supply component
Cost of supply on a whole of facility basis *($)
Click in fields below to enter values.
Capital cost
component
(where the
applicant
considers it
relevant to
the proposed
price)
Land costs
Construction costs
Refurbishment costs
Fit outs costs
Furnishing costs
Equipment costs
Other cost of supply components (where applicable)
Recurrent
cost
component
per annum
($)
Financing costs
(where
relevant to the
proposed
price)
Other cost of supply components (where applicable)
Leasehold cost (including annual rent and rate of return
adopted in the calculation of the capital amount)
* Where cost of supply is not on a whole of facility basis, please indicate the basis on which the cost is provided
(such as whether the cost is specific to the accommodation group).
6
Annexure A – Checklist
3.
This Annexure sets out the criteria that must be addressed in making an application for a price above the maximum
amount as determined by the Minister. These criteria are provided as a checklist for applicants to ensure that each
of these matters have been addressed in this application, or to supply information where it has not been provided in
other ways in this application form. Applicants may also choose to provide the information sought in Table A.1 by
way of highlighted plan.
Guidance on addressing quality, condition, size and amenity criteria is included at Section 3 of the Application
Guide.
Table A.1 Checklist – Specifications
Check items that you have addressed in
this application
Description (if not otherwise provided)
Click in fields below to enter text and values.
(i)
Location of the facility or service
(ii)
The size of the room/s or the part/s
of the room/s (in square metres)
(iii)
State the maximum number of
persons who may be provided with
accommodation in each room in the
accommodation group.
(iv)
Indicate whether the room/s have
access to a shared bathroom or
have a private ensuite
(v)
Nominate the common area/s in the
service that would be accessible to
the people being provided with
accommodation in the room/s and
their size (in square metres)
Table A.2 Checklist - Quality, Condition and Amenity
Check items that you have addressed in
this application
Description (if not otherwise provided)
Click in fields below to enter text.
(i)
Describe the quality and condition
of the room/s or the part/s of the
rooms, including furniture and
fittings, and any factors related to
amenity
(ii)
Describe the quality and condition
of the common area/s in the
service that would be accessible to
the people being provided with
accommodation in the rooms, and
any factors related to amenity
(iii)
Describe any specific
accommodation or design features
7
Check items that you have addressed in
this application
Description (if not otherwise provided)
of the accommodation which are
considered relevant to the
determination of the price
(iv)
Describe any specific
accommodation or design features
of the service which are
considered relevant to the
determination of the price and that
would be accessible to the people
being provided with
accommodation in the rooms
(v)
Describe any additional care or
services (other than care and
services specified in the Quality of
Care Principles 1997 for the
purposes of subsection 54-1(1) of
the Act) included in the amount
of the proposed accommodation
price
Declaration
I declare that the information supplied is true and correct and I have not withheld any information likely to
affect the assessment of this application.
Name
Date
8