{"id":"F2007B00705","name":"National Health Act 1953 - Determination pursuant to subsection 5D(1) (AOS 14/2004)","slug":"national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-14-2004","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":62501,"registerId":"commonwealth-F2007B00705-current","compilationNumber":null,"startDate":"2026-04-02","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Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can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":2595},"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"The instrument operates within the specific authority granted by section 5D of the National Health Act 1953, which empowers determinations specifying hospital-substitute treatment. The scope remains tightly constrained to defining when out-of-hospital services are deemed hospital treatment for benefit purposes, consistent with the original legislative intent."},"complexity_factors":["Multiple cross-references to sections 5A, 5C, 5D and subsection 4(1) of the National Health Act 1953","Conditional logic requiring 'direct substitution' for hospital treatment","Distinction between 'outreach services' (the treatment) and 'professional services' (doctor's fees) with different benefit rules","Temporal limitation: professional services only covered 'while' the outreach services are being provided","Dependency on defined terms from the parent Act ('applicable benefits arrangement', 'hospital treatment')"],"plain_english_summary":"This Determination lets private health insurers treat certain out-of-hospital care as the equivalent of hospital treatment, so health funds may pay benefits when that care directly substitutes for inpatient or day-hospital services. It affects insurers, providers and patients by enabling hospital-cover claims for care at home or in the community. Doctor fees are only payable when they occur alongside those specific substitute treatments."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-14-2004","history":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-14-2004/history","analysis":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-14-2004/analysis","conflicts":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-14-2004/conflicts","importantCases":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-14-2004/important-cases","documents":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-14-2004/documents"}}