EXPLANATORY STATEMENT
Issued by Authority of the Minister for Health and Ageing
National Health Act 1953
Determination pursuant to Subsection 5D(1)
(PSO 9 / 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, and on behalf of Toowong Private 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 - Toowong Private Hospital
This item specifies that relevant health services provided to patients by, or on behalf of,
Toowong Private Hospital in Queensland as part of Toowong Private Hospital Mental Health Assertive Community Treatment Program 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 November 2005 and remains in force until and including 31 October 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
September 2005
Overview
The National Health Act 1953, as amended by the Health Legislation Amendment Act (No. 1) 2001, was enacted to facilitate the provision of hospital treatment outside traditional hospital settings, allowing health funds to pay benefits for such services. This legislation addresses the gap in the previous regulatory framework where health funds could only cover such services if specific regulations were made under the Act. The 2005 determination under subsection 5D(1) of the Act specifies outreach services provided by Toowong Private Hospital in Queensland as part of its Mental Health Assertive Community Treatment Program. This determination enables these services, which include nursing care, medical treatment, and allied health services provided in patients' homes, to be recognised as outreach services, thus allowing health funds to cover them. The determination was made by the Minister for Health and Ageing, following a recommendation from the Private Sector Outreach Services Working Party, which assessed the application against clinical and patient outcome criteria. The determination was in force from 1 November 2005 to 31 October 2008.
Scope and Application
The National Health Act 1953 allows the Minister for Health and Ageing to specify certain services provided by, or on behalf of, a hospital or day hospital facility as outreach services, thereby deeming them hospital treatment. This is pursuant to subsection 5D(1) of the Act and enables health funds to pay benefits for these services under hospital cover policies, provided they are direct substitutes for hospital treatment. The outreach services specified in this determination apply to Toowong Private Hospital in Queensland, particularly those services provided as part of the Toowong Private Hospital Mental Health Assertive Community Treatment Program, which include nursing care, medical treatment, and allied health services delivered to patients in their homes. This determination, which was made following an application by Toowong Private Hospital and assessed by a Working Party comprising various health associations and consumer groups, is effective from 1 November 2005 until 31 October 2008. The Working Party's recommendation to the Minister is a critical part of the decision-making process, ensuring that the services meet established clinical standards and patient outcome criteria.
Key Provisions
The key operative sections of the legislation (subsection 5D(1) of the National Health Act 1953) permit the Minister for Health and Ageing to specify certain services provided by, or on behalf of, a specified hospital or day hospital facility as outreach services. When a service is determined to be an outreach service, it is deemed to be hospital treatment (section 5C of the Act), which allows health funds to pay benefits for these services under applicable benefits arrangements, provided they are a direct substitute for hospital treatment. The Determination pursuant to Subsection 5D(1) specifies that services provided by Toowong Private Hospital in Queensland, as part of the Toowong Private Hospital Mental Health Assertive Community Treatment Program, are outreach services. These services involve 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.
The Act imposes obligations on the parties and entities it governs, particularly on health funds. Health funds must recognise specified outreach services as hospital treatment and be prepared to pay benefits for these services under applicable benefits arrangements, as long as the services are provided as a direct substitute for hospital treatment. For Toowong Private Hospital, the obligation is to ensure that the services provided as part of the Mental Health Assertive Community Treatment Program meet the clinical standards and patient outcome criteria set out in the guidelines considered by the Private Sector Outreach Services Working Party.
The legislation does not explicitly outline offences, penalties, or civil/criminal consequences for breach. However, failure by health funds to comply with the Act by recognising specified outreach services as hospital treatment could result in non-payment of benefits for those services, potentially leading to disputes or legal actions. For Toowong Private Hospital, not meeting the clinical standards and patient outcome criteria could result in the services not being recognised as outreach services, thereby affecting the hospital's ability to have these services covered by health funds. The Working Party’s recommendation and the Minister's decision play a critical role in ensuring compliance with the Act's requirements.