Determination of eligibility

Where there is a query or a dispute about a person’s eligibility for publicly funded health and disability services, the Ministry of Health may be asked to make a determination of that person’s eligibility.

The current Health and Disability Services Eligibility Direction 2011 came into force on 14 April 2011. It is issued under section 32 of the New Zealand Public Health and Disability Services Act 2000.

Section B1(2) of the direction provides that the Ministry of Health is responsible for determining any dispute about eligibility:

‘The Ministry of Health must, if requested in writing to do so, determine any question or dispute concerning whether a person is eligible to receive services funded under the Act.’

The determination will state whether or not a person met the eligibility criteria in the Direction at the time they received health and/or disability services. The Ministry of Health has no discretion to amend the criteria set out in the Direction, or make any exceptions in individual circumstances.

Health service users or health service providers may request a determination of eligibility in writing to: eligibility@health.govt.nz.

All parties concerned will be notified of the determination request and invited to make a submission to the process. Submissions must outline all relevant facts concerning a person's eligibility at the time they receive/d services.

Where the eligibility criteria are clear for the circumstances, the determination may be in the form of a return email from a Ministry staff member.

Where there is not already a clear precedent for the circumstances, a determination panel will be convened, comprising:

• one policy representative with comprehensive knowledge of the Direction and its application
• one legal staff member
• one other person as appropriate to the determination required (eg, maternity services expert, public health specialist).

Except as set out in this page, the determination panel will have responsibility for determining its own process, depending on the requirements of the case.

When all required information has been collected, it will be provided to the panel for a determination to be made. The determination will not be made until the parties have been given reasonable opportunity to make representations on the question or dispute.

The panel will make a consensus determination, and that determination will be final. A copy of the determination will be provided in writing to the parties.