{"id":"F2005L00595","name":"Determination pursuant to subsection 5D(1) (PSO 3/2005)","slug":"determination-pursuant-to-subsection-5d-1-pso-3-2005","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":112850,"registerId":"commonwealth-F2005L00595-current","compilationNumber":null,"startDate":"2026-04-03","status":"Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can pay benefits under an applicable benefits arrangement (sometimes referred to as a “hospital cover policy”) for any service specified in this Determination if, and only if, the service is provided to a patient as a direct substitute for hospital treatment that would otherwise be provided in a hospital or day hospital facility (see the definition of \"outreach service\" in subsection 4(1) of the National Health Act 1953 (the Act) as well as sections 5A, 5C and 5D of the Act).\n\nNote 2: Health funds can also pay benefits for professional services that are rendered to a patient by a medical practitioner while the services specified in this Determination are being provided, so long as those services are being provided as a direct substitute for treatment that would ordinarily be provided in a hospital or day hospital facility. Under section 5C of the Act outreach services (defined in subsection 4(1) of the Act) are deemed to be a form of \"hospital treatment\". Under section 5A of the Act health funds can provide benefits under an applicable benefits arrangement for hospital treatment and any professional services rendered to a patient by a medical practitioner while the hospital treatment is being provided. The Determination in effect allows health funds to provide benefits under an applicable benefits arrangement for those out-of-hospital professional services that are provided while services that are specified in this Determination are being provided as a direct substitute for treatment that would ordinarily be provided in a hospital or day hospital facility. However, the Determination does not permit health funds to provide benefits for professional services provided out-of-hospital in any other situation.","sortOrder":0}],"analysis":{"kimi_summary":{"_metrics":{"model":"kimi-k2.5","source":"moonshot-batch","completionTokens":2569},"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"This determination operates within the original scope of subsection 5D(1) of the National Health Act 1953, which authorizes the Minister to specify which out-of-hospital services qualify as outreach services. It implements the statutory framework for deeming specific services as hospital treatment for insurance purposes without expanding beyond the legislative intent."},"complexity_factors":["Multiple conditional requirements (service must be listed in determination AND be direct substitute for hospital care)","Cross-references to three sections of the National Health Act 1953 (sections 5A, 5C, and 5D)","Distinction between outreach services (facility/treatment services) and professional services (medical practitioner fees)","Deemed legal status (outreach services treated as 'hospital treatment' by operation of section 5C)","Nested scope limitations (professional services covered only when rendered during listed outreach services)"],"plain_english_summary":"This determination tells private health insurers which out-of-hospital treatments qualify as \"outreach services\" that can be paid under hospital cover (rather than extras), and that doctors’ visits tied to those outreach treatments are also covered. It affects insurers, hospitals, practitioners and patients receiving hospital-equivalent care outside inpatient settings.\n\nInsurers may only pay when the service is on the official list and truly substitutes for hospital care — ordinary GP or routine out‑of‑hospital visits remain excluded."}},"importantCases":[],"_links":{"self":"/api/acts/determination-pursuant-to-subsection-5d-1-pso-3-2005","history":"/api/acts/determination-pursuant-to-subsection-5d-1-pso-3-2005/history","analysis":"/api/acts/determination-pursuant-to-subsection-5d-1-pso-3-2005/analysis","conflicts":"/api/acts/determination-pursuant-to-subsection-5d-1-pso-3-2005/conflicts","importantCases":"/api/acts/determination-pursuant-to-subsection-5d-1-pso-3-2005/important-cases","documents":"/api/acts/determination-pursuant-to-subsection-5d-1-pso-3-2005/documents"}}