National Health Act 1953 - Determination under Schedule 1, paragraph (1)(bj) (HIB 06/2006)

Administered by Department of Health, Disability and Ageing

Legislation au F2006L00856 Not in force Legislative Instrument

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EXPLANATORY STATEMENT

 

Issued by Authority of the Minister for Health and Ageing

 

National Health Act 1953

Determination under Schedule 1, paragraph (1)(bj)

(HIB 06/2006)

 

Schedule 1, paragraph (1)(bj) of the National Health Act 1953 (the Act) provides that the Minister may determine the minimum levels of benefit payable by a registered health benefits organization for an episode of hospital treatment provided to contributors, other than in emergencies, in a hospital or day hospital facility with which the organization does not have a hospital purchaser-provider agreement which covers such treatment.  These benefits are known in the industry as “default benefits”.

 

This determination repeals and replaces the determination made on 24 June 2005 (as amended). Rather than registering the principal determination and all subsequent amendments to the principal determination on the Federal Register of Legislative Instruments as required under the Legislative Instruments Act 2003, I have pursued the alternative option allowed under the Legislative Instruments Act 2003 of repealing and remaking the determination in a consolidated form.   This determination is comprised of seven Schedules setting out the minimum levels of benefit which are payable for a range of hospital treatment. 

 

This determination also incorporates some substantive amendments which are explained below.

 

Amendments to Schedule 4

 

This determination makes amendments to Schedule 4 (Nursing Home Type Patient Accommodation).  Schedule 4 sets out benefit levels payable for overnight accommodation to the Nursing Home Type Patients (NHTPs) in private and recognized (public) hospitals.  The charge for providing hospital treatment to NHTPs in private hospitals has been capped at $111.10 per day.  The default benefit for NHTPs in private hospitals is set by subtracting the amount of the patient contribution from the capped amount.  The patient contribution, which is not insurable, is calculated by reference to pension rates and set by the Minister’s Determination under subsection 3(1) of the Health Insurance Act 1973. The default benefit payable to NHTPs in private hospitals is modified each time that a change to the pension rate leads to a change to the amount of the patient contribution.

 

This determination adjusts the default benefit payable to NHTP’s in recognized public hospitals within New South Wales and Tasmania to take into account a recent change to the amount of the patient contribution.

 

This determination does not change the default benefit payable to NHTP’s in private hospitals in all States/Territories and in public hospitals in the Northern Territory, the Australian Capital Territory, Victoria, South Australia, Western Australia and Queensland. 

 

Amendment to Schedule 5

 

Schedule 5 of the Determination made on 24 June 2005 (HIB 11/2005) (as amended) set out the level of benefits payable for surgically implanted prostheses, in hospitals and day hospital facilities in all States and Territories. The National Health Amendment (Prostheses) Act 2005 introduced new arrangements for listing and paying benefits for prostheses and human tissues. This Act received Royal Assent on 21 March 2005. The effect of the amendments was that Schedule 5 of Schedule 1, paragraph (1)(bj) to the Act has been replaced, in its entirety, by a new determination made under subsections 73AAG(6) and (7) of the Act.   

 

 

 

 

Amendments to Schedules 5, 6, 7 and 8

 

Schedules 5,6,7 and 8 have been re-numbered to reflect the omission of Schedule 5 from the determination made under Schedule 1, paragraph (1)(bj) to the Act on 24 June 2005 (as amended).

 

This determination sets out the second tier level of benefits payable for accommodation in private hospitals and day hospital facilities in Schedule 5.

 

This determination sets out the level of benefits payable for Care Plans and Case Conferencing in hospitals and day hospital facilities in all States and Territories in Schedule 6.

 

This determination sets out the level of benefits payable for Outreach Services provided to a patient by, or on behalf of, a hospital or day hospital facility in all States and Territories in Schedule 7

 

The previous Schedule 8 has been omitted.

 

Consultation

 

The amendments to Schedule 4 in relation to default benefits for NHTPs in public hospitals in all States and Territories are set in accordance with the daily bed rate for NHTPs calculated by each State and Territory minus the patient contribution as set by the Minister’s Determination under subsection 3(1) of the Health Insurance Act 1973.  All States and Territories decide whether to adjust the daily bed rate for NHTPs each time there is a change to the standard pension rate.  The Minister amends the default benefit payable for NHTPs in each State and Territory every time a particular State or Territory notifies the Commonwealth that it has modified its daily bed rate for NHTPs.

 

This determination commences on 20 March 2006. The determination and this explanatory statement have been lodged for registration on the Federal Register of Legislative Instruments.

 

 

 

 

 

 

 

 

 

 

 

PRIVATE HEALTH INSURANCE BRANCH

DEPARTMENT OF HEALTH AND AGEING

MARCH 2006

Overview

The National Health Amendment (Prostheses) Act 2005 was enacted to address the need for a new framework for listing and paying benefits for prostheses and human tissues within the National Health Act 1953. This legislation was introduced by the Australian Parliament to ensure that the provision of health services and benefits is consistent and equitable across the nation. The policy objective was to improve the efficiency and transparency of the health benefits system, particularly in relation to prostheses and human tissues. The Act facilitated the updating of the default benefits, which are the minimum levels of benefit payable by health benefits organizations for certain hospital treatments, by allowing the Minister for Health and Ageing to make determinations under the National Health Act 1953. The explanatory statement for the 2006 determination under Schedule 1, paragraph (1)(bj) of the Act, made by the Minister for Health and Ageing, details the consolidation and amendment of previous determinations to reflect the new legislative framework and to adjust the benefits payable for certain treatments in both private and public hospitals.

Scope and Application

The National Health Act 1953, as amended by the determination under Schedule 1, paragraph (1)(bj)(HIB 06/2006), applies to registered health benefits organizations and their contributors. This determination focuses on setting the minimum levels of benefit, known as "default benefits," payable for hospital treatments provided in facilities that do not have a hospital purchaser-provider agreement with the health benefits organization. These default benefits are applicable to contributors undergoing treatment in hospitals or day hospitals outside their agreements. The scope of this legislation is national, extending across all states and territories in Australia, and it applies to various treatments and services outlined in the determination's schedules. Notably, the determination does not apply to emergency treatments and has specific provisions for different types of hospital accommodations and services, including nursing home type patients, prostheses, care plans, and outreach services. This determination includes amendments to previous schedules, particularly adjusting the default benefits for nursing home type patients in public hospitals within specific states, and it incorporates changes resulting from the National Health Amendment (Prostheses) Act 2005. The determination is comprehensive, repealing and replacing previous determinations to ensure clarity and consistency in the application of default benefits across the health sector.

Key Provisions

The main operative sections of the determination under Schedule 1, paragraph (1)(bj) of the National Health Act 1953, set out the minimum levels of benefit payable by registered health benefits organisations for hospital treatment provided to contributors in facilities without a hospital purchaser-provider agreement. These "default benefits" are detailed across seven schedules, which specify the benefits payable for various types of hospital treatment. Notably, Schedule 4 addresses the benefits for Nursing Home Type Patients (NHTPs) in both private and public hospitals, while Schedules 5, 6, 7, and 8 outline benefits for prostheses, care plans, case conferencing, and outreach services respectively. The schedules reflect changes in patient contributions and daily bed rates, ensuring that benefits are adjusted accordingly. The obligations imposed by the Act on registered health benefits organisations include ensuring that they provide the specified minimum levels of benefits for hospital treatment as outlined in the schedules. These organisations must adhere to the caps on charges and the calculation methods for patient contributions. Additionally, they are required to adjust their benefit levels in response to changes in pension rates or daily bed rates as notified by the respective states or territories. The Minister for Health and Ageing plays a crucial role in setting these rates and benefits, ensuring that they are fair and reflective of current economic conditions. In terms of offences, penalties, or consequences for breach, the Act does not explicitly outline specific civil or criminal penalties for non-compliance with the default benefit provisions. However, failure to adhere to the specified minimum benefit levels could result in legal action by contributors or oversight from regulatory bodies. Additionally, registered health benefits organisations must comply with the requirements to avoid any reputational damage or loss of accreditation, which could indirectly lead to financial penalties or reduced consumer trust. It is important for these organisations to maintain accurate records and transparent communication with contributors to ensure compliance with the Act’s provisions.

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Sourced from the Federal Register of Legislation at 26 August 2026. For the latest information on Australian Government law please go to https://www.legislation.gov.au.