Eligibility A-Z for service providers

New Zealand’s universal accident insurance scheme (ACC) covers treatment costs for accidental injuries for New Zealand citizens, residents and visitors alike. It covers acute accident-related hospital treatment, and a wide range of other services approved by ACC. Claims for ongoing treatment must be accepted by ACC, and part charges may apply.

While ACC covers visitors’ injury-related treatment, comprehensive travel insurance is strongly recommended to cover repatriation expenses and claims not accepted by ACC.

To find out more about the scheme, visit the ACC website.

Each DHB is responsible for deciding what kind of treatment is classed as ‘acute’ or ‘elective’. Acute care is generally the medical treatment:

•  without which a person will die, or
•  without which the person’s condition could deteriorate to become life threatening or significantly debilitating, or
•  needed to establish whether a condition is life threatening or significantly debilitating.

Anyone requiring acute services can receive the services they require. If they are not eligible, they can expect to be invoiced for the services they received. Ineligible people needing ‘elective’ services may receive the treatment through the public system, where there is capacity beyond meeting the needs of the eligible population. In some cases they will be asked for payment in advance.

If a person is too unwell to make an informed decision about whether they want further treatment, and a clinician determines that treatment is necessary to prevent loss of life or significant disability, treatment should be provided. If the person is not eligible for that treatment to be publicly funded, they would be asked to pay afterwards.

Older people must be eligible for the full range of publicly funded health and disability services in order for disability support services, residential care and other services for older people to be publicly funded.

Eligibility for publicly funded services should be known when a person has a needs assessment by a NASC agency.

To be eligible to receive publicly funded age-related disability support services, a person would need to:

• be a New Zealand citizen; OR
• be an Australian citizen or permanent resident who has been living or is intending to live in New Zealand for two years or more; OR
• hold a resident visa or permanent resident visa (or a residence permit if issued prior to 29 November 2010) OR
• be a refugee, protected person or victim of people trafficking.

People applying for refugee or protection status, or appealing to the Immigration and Protection Tribunal against refusal of refugee/protected person status are eligible for the full range of publicly funded services. However, they will become ineligible if their claim for status is not successful, or their appeal is not upheld.

To be eligible for public funding for aged residential care (a residential care subsidy) an older person must meet the eligibility criteria for public funded health and disability services and be assessed as requiring residential care indefinitely, and undergo a financial means assessment. If they are not eligible for publicly funded health and disability services, a person can access private care in a residential care setting, but if their personal funds are exhausted, and they are not eligible for public funding or not assessed as requiring residential care, no public funds will be made available.

Not all Australians have eligibility

There are two different eligibility classes for Australians. Australian citizens and Australian permanent residents who have migrated to New Zealand are eligible for the full range of services, provided they have or intend to stay here for at least two years.

Australian residents who are not intending to stay for two years or longer are eligible for immediately necessary hospital and maternity services and pharmaceuticals. They’ll need to pay the full cost of primary health care consultations (eg, with a local doctor or nurse) often called the ‘casual’ rate. This is what New Zealanders pay if they choose not to enrol.

Why there's a separate eligibility criteria for Australians

We need to distinguish between Australians (citizens and permanent residents) eligible for any publicly funded service, and Australians only eligible for some publicly funded services.

Under a reciprocal agreement between the Australian and New Zealand Governments, Australian residents on a temporary stay in New Zealand can access immediately necessary hospital and maternity services, and pharmaceuticals. Australians migrating here for a two year stay or longer are eligible for the full range of publicly funded services.

Other New Zealand residence class visa holders will have already demonstrated to the New Zealand Government that they intend to stay in New Zealand long term, so are not asked to demonstrate they have stayed or intend to stay in New Zealand for at least two years.

List of services Australian residents can access under the reciprocal health agreement

Immediately necessary pharmaceuticals, hospital and maternity care clinically necessary for the diagnosis, alleviation or care of the condition requiring attention, on terms no less favourable than applies to New Zealanders. Each case is assessed on its merits, against the conditions of the reciprocal health agreement.

Read more about the reciprocal health agreement between New Zealand and Australia

What is an Australian resident?

Australian resident is defined by the Australian Health Insurance Act 1973 as a person who resides in Australia and includes:

• an Australian citizen
• an Australian permanent resident visa holder or a resident return visa
• a person who holds an Australian temporary visa and is waiting to have their application for a permanent visa determined
• holds an Australian work visa.

A full list is available on the Commonwealth Consolidated Acts website.

Australian residents may be covered under the reciprocal health agreement with Australia when on a temporary stay in New Zealand.

Only those with Australian citizenship and Australian permanent residency (eg, a return resident visa in their passport) can be eligible for the full range of services in New Zealand (ie, if they are staying in NZ for two years dating back to their arrival date)

New Zealand citizens living overseas can come back for health care services for their children

A child under 18 in the care and control of a New Zealand citizen or permanent resident is eligible, provided the eligible parent can prove their eligibility and that they are the parent of that child. They may receive hospital treatment at any hospital in the same way as other New Zealanders.

However, if visiting a doctor, they will need to pay the same rate as a casual (non-enrolled) New Zealander as they probably don’t meet the requirements for PHO enrolment.

There are three main ways a person can become a New Zealand citizen:

• by birth
• by grant, and
• by descent.

Citizenship by birth

Until the end of 2005, most children born in New Zealand, the Cook Islands, Niue and Tokelau were automatically New Zealand citizens at birth. Since 1 January 2006, children born in New Zealand, the Cook Islands, Niue and Tokelau have been able to acquire New Zealand citizenship by birth only if at least one of their parents:

• is a New Zealand citizen, or
• has permanent residency (ie, is entitled to remain in New Zealand or Australia indefinitely), or
• is entitled to reside indefinitely in the Cook Islands, Tokelau or Niue.
• Since January 2006, birth certificates have confirmed New Zealand citizenship by birth.

Citizenship by grant

New Zealand citizens by grant are people who are a recipient of a grant of New Zealand citizenship, for example, after having lived in New Zealand for several years. A citizenship certificate is issued to recipients of citizenship by grant.

Citizenship by descent

People born outside New Zealand to a parent (or parents) who is a New Zealand citizen (other than by descent) at the time of their birth can make a claim to New Zealand citizenship by descent. Many children adopted outside New Zealand by New Zealand citizens are also granted citizenship by descent, provided several criteria are met. They will hold a citizenship by descent certificate.

The New Zealand Citizenship Office, Department of Internal Affairs, administers grants of citizenship, confirmation and denials of citizenship and descent registrations. For more detailed information on New Zealand citizenship, visit the Department of Internal Affairs website.

Treatment for tuberculosis is publicly funded prior to compulsory treatment orders

If a person has or is suspected of having tuberculosis, the surveillance, diagnosis, treatment and follow-up services for tuberculosis may be publicly funded, to the extent appropriate in the circumstances to address risks to other persons.

The same provisions apply to infectious and quarantinable diseases listed in the schedule 1 of the Health Act 1956.

What happens to patients who have become ineligible during a course of treatment

The Direction states that eligibility is assessed at the time services are received. If a person becomes ineligible during a course of treatment, they're liable for the cost of treatment received when they are ineligible.

 Foreign diplomats and their family members are not eligible for publicly funded health and disability services. The Government they’re representing is responsible for covering their health costs. They may receive medical care in the public health system but must pay for all medical and associated costs.

Foreign diplomats and their family members requiring acute care will receive it, and will later be invoiced for the services received.  

Foreign diplomats and their family members seeking elective services through the public health system will be treated only where there is capacity beyond meeting the needs of the eligible population. Provision of treatment is decided on a case-by-case basis, by the treating District Health Board. In some cases, payment may be sought in advance. 

Foreign diplomats and their family members are covered under the accident compensation scheme and may receive medical treatment under the public system as the result of an accident, including motor vehicle accidents. Foreign diplomats may be eligible for publicly funded health care in situations where they otherwise meet the eligibility requirements of the 2011 Direction. This also applies to Consular and Official staff, and their family members.

Please refer any queries to Protocol Division of the Ministry of Foreign Affairs and Trade, Wellington.

Front line staff and other health practitioners can consult their DHB’s finance and/or legal team. Enquiries can also be made to the Ministry of Health contact centre on 0800 855 066 or eligibility@health.govt.nz. They will help you to work through the eligibility requirements and understand the eligibility criteria.

Where there is a question or dispute, a request can be made in writing to the Ministry of Health to make a determination of eligibility.

For foreign nationals, being lawfully in New Zealand generally means that they hold a visa permitting them to stay in New Zealand. This is important to understand when assessing the eligibility of work visa holders whose work visa is not for two years, but immediately prior, they were in New Zealand. If time spent lawfully in New Zealand immediately prior to the work visa and the length of the work visa equals two years or longer, the work visa holder would be eligible.

Before 2 April 1974, British nationals were able to enter New Zealand and stay indefinitely. Health service providers will not know this, however, by looking at their passport, and some may not even hold a passport as they have not since been out of New Zealand.

Providers can check with Immigration NZ if the person holds a residence class visa. If INZ is unable to confirm this, the person can visit their local immigration branch to have their residency confirmed. In some cases, where they are able to provide sufficient proof of having lived here since March 1974, confirmation can be provided on the same day.

The Health and Disability Services Eligibility Direction 2011 defines maternity-related services for this group as:

1. primary maternity services as per clause B1 of the Primary Maternity Services Notice 2007
2. all maternity services provided by DHBs, and
3. any other secondary or tertiary services for a condition of the mother or child that a clinician has determined will significantly impact on the pregnancy or its outcome.

Note: If maternity services are being funded on the basis of partnership to an eligible person, but that partnership ends, if the child is born a New Zealand citizen, the maternity-related services may be publicly funded.

New Zealand citizens are eligible for publicly funded health and disability services when they are in New Zealand, regardless of the time spent away from New Zealand.

They may be scheduled for public hospital services before they return to New Zealand, but will be subject to the same assessment criteria and wait times as other eligible people.

NHI numbers are assigned to anyone receiving health or disability services, regardless of their eligibility status. Their purpose is not to record eligibility, but to correctly identify people to access their unique health record, to ensure they get the best care and support.

Citizens of the Cook Islands, Niue and Tokelau are issued with New Zealand passports to travel. When in New Zealand, they are eligible for publicly funded health and disability services. There may be waiting times for some services, and part-charges apply (for example, for primary care or pharmaceuticals) on the same basis as for other New Zealanders.

Residents of those islands who are not citizens must meet one of the other eligibility criteria before they can access publicly funded services.

The New Zealand Government funds special health services with the governments of Fiji, Samoa, Tonga, Kiribati, Tuvalu and Vanuatu through an agreement with those countries. If a person is referred through this agreement, it is advisable for health service providers to ensure that country’s government has been advised of the likely cost, and has agreed to pay. Enquiries can be directed to the Ministry of Foreign Affairs and Trade.

People who arrive in New Zealand for medical treatment without going through their own government channels are likely to be refused help from their own government, and unless they met one of the eligibility criteria they would not be eligible for publicly funded care from New Zealand.

Foreign nationals allowed to remain permanently in New Zealand may hold:

• a resident visa
• a permanent resident visa, or
• a residence visa, residence permit, and a returning resident’s visa.

These are all ‘residence class visas’ under the Immigration Act 2009.

Since 29 November 2010, resident and permanent resident visas have been issued in place of residence permits and returning resident’s visas. These replace residence visas, resident’s permits and a returning resident’s visas. Residence permits are now deemed resident class visas under the Immigration Act 2009.

Foreign nationals are eligible if they hold a valid (current):

• resident visa
• permanent visa, or
• a residence permit issued before 29 November 2010.

Note: If a person has a letter stating their residency application has been accepted in principle, they are not eligible
until their residency application has been finalised, which is when they will be issued residency labels in their passport.

Prior to 29 November 2010, visas allowed foreign national to travel to New Zealand. Permits gave that person permission to stay in New Zealand for a particular purpose (eg, to work, study, visit, or reside permanently). Permits granted overseas were in the form of a label in the passport and a stamp at the border. If a foreign national had a current permit, they were lawfully in New Zealand.

Permits ceased to be issued from 29 November 2010, under the Immigration Act 2009. Visas are now issued for both travel rights and lawful stay. Permits issued prior to that date are deemed visas under the Act. This is particularly important to know when assessing eligibility for work visa holders. Check that it is the time the person is allowed to stay in New Zealand that is being counted.

The Minister of Health. For services funded through Health NZ, this is generally done through Ministerial Directions under section 32 of the New Zealand Public Health and Disability Services Act 2000.

The Minister is prevented by law from making a direction or notice about a specific person or activity.

The current (2011) Ministerial Direction on eligibility provides a specific role for the Ministry of Health in determining eligibility if there is a question or dispute about whether a person meets the criteria. The Ministry determination is specific to the person and their particular circumstances, and must be consistent with the criteria. There is no provision to make exceptions to the criteria.

The reciprocal agreement with Australia covers immediately necessary pharmaceuticals (and maternity services and hospital services).

The reciprocal agreement with the United Kingdom covers services for conditions that arose in New Zealand, became worse while in New Zealand or without treatment would have become acutely exacerbated. If this is true, the pharmaceuticals may be funded (provided other conditions of the reciprocal health agreement are satisfied). Otherwise United Kingdom nationals should bring their regular medications with them, or have health insurance or the means to pay for regular medications.

Note: Only UK citizens/UK passport holders are covered under the reciprocal agreement.

People who have applied for refugee status are eligible for publicly funded health and disability services.

To prove their status they should show the letter from Immigration New Zealand, advising that their application is being processed.

If the letter is more than three months old, ask the person for confirmation that their application has not yet been granted or declined. Immigration New Zealand usually writes to the client if their application takes more than three months to process.

If the letter is more than six months old, ask the person to obtain written confirmation from Immigration New Zealand before giving them publicly funded services. Alternatively, contact the Refugee Status Branch on the number above.

Asylum seekers are refugee status claimants. Once an asylum seeker applies for refugee status or has this application accepted, they are eligible for publicly funded services under the same criteria as refugees. If their application for refugee status is denied and they don’t appeal against the decision to deny them refugee status, or they lose an appeal, they are no longer eligible.

The Refugee Status Branch decision times increased to over a year for most asylum seekers and has limited resources to issue updated claim letters to clients every three months so they will accept claim letters as is. Email: rsu@mbie.govt.nz or phone: +64 9 928 2236

Student visa holders may be eligible for any publicly funded service if they are under 18 and the child of an eligible person. They may also receive services funded for anyone in New Zealand, for example, ACC or compulsory health services.

Eligibility for long term student and visitor visa holders ended on 15 April 2011.

Under the 2003 Health and Disability Services Eligibility Direction, student visa holders who met the eligibility criteria of the 2000 eligibility direction had their eligibility ‘grandparented’ while they remained on consecutive visitor visas, which continued their health cover while they completed their studies.

If a migrant is not eligible for publicly funded services but has a sponsor for their visa, the sponsor may be responsible for meeting some unpaid hospital debts. This applies to sponsored visas commencing on or after 29 November 2010. Contact Immigration NZ for further information.

Only United Kingdom citizens ordinarily living in the United Kingdom are covered by this agreement, and subject to certain conditions. Visit the Reciprocal Health Agreement page for more information.

If laboratory tests or medicines are prescribed by a doctor for prompt treatment of a condition that either arose in New Zealand or became (or would have become if not treated) unexpectedly worse while here in New Zealand, then the person is eligible for publicly funded subsidies.

However, if a New Zealand citizen would have had to pay for the same test, so would the United Kingdom citizen.

A reciprocal agreement between New Zealand and the United Kingdom provides for treatment that, in the opinion of a medical practitioner (doctor) is required promptly for a condition that arose after arrival in New Zealand, or for a pre-existing condition that required, or would have required urgent treatment. This is generally interpreted as covering, for pregnancy, full-term childbirth services, or premature delivery.

Related conditions, such as toxemia, would also be covered if, in the opinion of a medical practitioner, prompt treatment was required.

Routine antenatal and postnatal services would not be covered.

Visitor visa holders may be eligible for any publicly funded service if they are under 18 and the child of an eligible person. They may also receive services funded for anyone in New Zealand, for example ACC, compulsory health services, or maternity-related services as the partner of an eligible person.

Adult visitor visa holders are usually ineligible for the full range of publicly funded health and disability services.

Eligibility for long term visitor visa holders ended on 15 April 2011.

Under the 2003 Health and Disability Services Eligibility Direction, visitor visa holders who met the eligibility criteria of the 2000 eligibility direction had their eligibility ‘grandparented’ while they remained on consecutive visitor visas, to enable them to become eligible under other criteria (eg. permanent residency), or until they left New Zealand.

See the 2000 Eligibility Direction on the Department of Internal Affairs website and the 2003 Eligibility Direction for more information.

Work visa holders are eligible if their visa or visas allow a consecutive stay of two or more years.

The work visa must be the current visa (adult work visa holders become ineligible if they change to a student visa), which can be added to the time spent lawfully in New Zealand immediately prior to reach the minimum requirement of two years.

Work visas start on the person’s first day in New Zealand.