EXPLANATORY STATEMENT
Issued by Authority of the Minister for Health and Ageing
National Health Act 1953
Determination pursuant to Subsection 5D(1)
(PSO 6 / 2005)
Subsection 5D(1) of the National Health Act 1953 (the Act) provides that the Minister may, by written determination, specify services provided by, or on behalf of, a specified hospital or day hospital facility for the purposes of the definition of outreach service in subsection 4(1) of the Act. Once a service is determined to be an outreach service then it is deemed to be hospital treatment (section 5C of the Act). Health funds can then pay benefits for those services (and associated professional services) under applicable benefits arrangements (hospital cover policies), provided that the services are provided as a direct substitute for hospital treatment that would otherwise be provided in a hospital or day hospital facility.
The provisions relating to outreach services were inserted into the Act by the Health Legislation Amendment Act (No. 1) 2001. These provisions were enacted to allow health funds to pay benefits for services that are provided to a patient as a direct substitute for hospital treatment, such as hospital in the home, under applicable benefits arrangements. Prior to these provisions being inserted, health funds could only pay benefits for such services if regulations modifying the Act were made under subsection 140(2) of the Act.
Consultation
A facility that wishes a determination to be made in relation to an outreach service it provides makes an application to the Department of Health and Ageing. Each application is initially assessed by the Private Sector Outreach Services Working Party (the ‘Working Party’). The Working Party members are drawn from: the Australian Health Insurance Association, the Australian Private Hospitals Association, the Committee of Presidents of Medical Colleges, the Royal College of Nursing Australia, Catholic Health Australia, Ambulatory Care Australia and the Consumers’ Health Forum. The Working Party considers each application against guidelines that contain criteria about clinical standards and patient outcomes. The guidelines have been designed to assist the Working Party to assess whether the services to be provided are of a suitable quality. The Working Party makes a recommendation to the Minister as to whether the services meet the guidelines, and the Minister (or delegate) decides whether to make a determination under subsection 5D(1) of the Act, taking into account the recommendation of the Working Party.
This Determination specifies outreach services to be provided by, or on behalf of Sydney Adventist Hospital.
Item-by-item details of the Schedule
Specified services provided by, or on behalf of, specified hospitals or day hospital facilities.
Item 1 – Definitions
This item defines terms used in the Schedule.
Item 2 - Specified services and hospitals
Item 2 - Sydney Adventist Hospital
This item specifies that relevant health services provided to patients by, or on behalf of,
Sydney Adventist Hospital in New South Wales as part of Sydney Adventist Hospital/Hospital in the Home (HITH) are outreach services for the purposes of subsection 4(1) of the Act. This outreach service involves the provision of treatment (which may include nursing care, treatment by a medical practitioner or the provision of allied health services) to patients in their own homes.
This determination commences on 1 August 2005 and remains in force until and including 31 July 2008. The determination and this explanatory statement have been lodged for registration on the Federal Register of Legislative Instruments
ACUTE CARE DIVISION
DEPARTMENT OF HEALTH AND AGEING
June 2005
Overview
The National Health Act 1953 was amended to include provisions for outreach services, allowing health funds to pay benefits for services that substitute hospital treatment, such as hospital in the home. This was achieved through the Health Legislation Amendment Act (No. 1) 2001, which sought to address the gap where such benefits could only be paid if specific regulations were made under the Act. Pursuant to this amendment, the Minister for Health and Ageing, through the Department of Health and Ageing, has the authority to specify services provided by, or on behalf of, a hospital or day hospital facility as outreach services under subsection 5D(1) of the Act. Once determined, these services are deemed hospital treatment, enabling health funds to pay benefits for them. This determination process involves an application from the facility, which is assessed by the Private Sector Outreach Services Working Party against clinical standards and patient outcomes criteria, with a final decision made by the Minister. The Determination pursuant to Subsection 5D(1) (PSO 6 / 2005) specifies outreach services to be provided by Sydney Adventist Hospital, involving treatment provided to patients in their own homes, effective from 1 August 2005 to 31 July 2008.
Scope and Application
The National Health Act 1953, through its provisions concerning outreach services, allows for specific services provided by or on behalf of a hospital or day hospital facility to be determined as outreach services, thereby qualifying them as hospital treatment. This is contingent on the services being deemed a direct substitute for in-hospital treatment, enabling health funds to pay benefits under applicable benefits arrangements. The legislation applies to entities such as Sydney Adventist Hospital, which can apply for a determination to be made regarding specific services they provide, such as hospital in the home services, that are considered outreach services. The determination process involves the Private Sector Outreach Services Working Party, comprising representatives from various healthcare associations and consumer groups, which assesses applications based on clinical standards and patient outcomes, before recommending to the Minister for a decision. This determination, specific to Sydney Adventist Hospital in New South Wales, was made under subsection 5D(1) of the Act, and is effective from 1 August 2005 until 31 July 2008. The Act’s jurisdictional reach is Commonwealth-wide, applying across Australia, but this determination pertains specifically to the services provided by Sydney Adventist Hospital. The Act does not explicitly state exclusions or thresholds for this determination but allows for further specification through subordinate instruments.
Key Provisions
The key provisions of the Determination under Subsection 5D(1) of the National Health Act 1953 (the Act) focus on defining and specifying outreach services provided by Sydney Adventist Hospital (sections 1 and 2). Outreach services, as defined in this context, include the provision of treatment such as nursing care, medical treatment by a practitioner, or allied health services, delivered to patients in their homes as part of the Hospital in the Home (HITH) program. This determination is effective from 1 August 2005 until 31 July 2008, and it aims to ensure these services are recognised as hospital treatment, allowing health funds to pay benefits for such services under applicable benefits arrangements.
The Act imposes specific obligations on Sydney Adventist Hospital and health funds. Sydney Adventist Hospital must ensure that the outreach services provided meet the clinical standards and patient outcomes as per the guidelines set by the Private Sector Outreach Services Working Party. This Working Party, which comprises representatives from various healthcare-related bodies, assesses each application to determine if the services align with the established criteria. Health funds, on the other hand, are required to pay benefits for these specified outreach services, provided they are a direct substitute for hospital treatment that would otherwise be provided in a hospital setting.
Failure to comply with the requirements set forth in the Act may lead to legal consequences. While the Act does not explicitly outline specific offences, penalties, or consequences for breaches, it does mention that the Minister (or a delegate) makes the final determination on whether the services meet the guidelines. Non-compliance could potentially result in the denial of benefits by health funds for services that do not meet the specified criteria, impacting both the hospital and the patients who rely on these services. The overarching regulatory framework of the Act ensures that any significant deviations from the outlined provisions are addressed, maintaining the integrity and effectiveness of the outreach services provided.