Schedule 4―Nursing‑home type patient accommodation: hospitals in all States/Territories

1. Circumstances

(1) For rule 5 of Part 2 of these Rules, the circumstances specified for hospital treatment to which this Schedule applies are that the treatment is provided:

(a) to a nursing‑home type patient; and

(b) at a hospital.

Note: The definition of hospital treatment in section 121‑5 of the Act includes that the treatment is provided either at the hospital or provided or arranged with the direct involvement of a hospital. This Schedule sets out benefit requirements only for treatment provided at the relevant hospital ― see paragraph 121‑5(1)(c) of the Act.

2. Interpretation

Nursing‑home type patient, in relation to a hospital, means a patient who has been provided with hospital treatment whether:

(a) acute care; or

(b) accommodation and nursing care, as an end in itself; or

(c) a mixture of both,

for a continuous period of hospitalisation exceeding 35 days (35‑day period), but a patient receiving acute care immediately after the 35‑day period does not become a nursing‑home type patient unless the period of acute care ends and the patient is then provided with accommodation and nursing care, as an end in itself, as part of a continuous period of hospitalisation.

Note 1: 'Continuous period of hospitalisation' is defined in rule 3 of Part 1 of these Rules.

Note 2: Clause 4 deals with nursing‑home type patients whose care needs change to requiring acute care.

Note 3: If there is disagreement as to whether a patient is, or is not, a nursing‑home type patient, an insured person, a private health insurer or a health care provider may make a complaint to the Private Health Insurance Ombudsman under Part 6‑2 of the Act. The Ombudsman has various powers to deal with complaints, including conducting mediation if the complainant agrees.

3. Application

(1) Clause 2 of this Schedule applies to a patient who on or after the day on which the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) commence:

(a) returns to hospital for hospital treatment at a hospital not later than 7 days after receiving hospital treatment at that hospital or another hospital; or

(b) is otherwise admitted to a hospital for hospital treatment at the hospital.

(2) If subclause (1) does not apply to a patient, the definition of 'nursing‑home type patient' in these Rules before the commencement of the Private Health Insurance (Benefit Requirements) Amendment Rules 2007 (No. 4) continues to apply to that patient.

Note: Clause 4 deals with nursing‑home type patients whose care needs change to requiring acute care.