{"id":"F2005B01909","name":"National Health Act 1953 - Determination pursuant to subsection 5D(1) (AOS 9/2004)","slug":"national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-9-2004","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":112261,"registerId":"commonwealth-F2005B01909-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Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can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":3555},"content_quality":"ok","complexity_score":5,"scope_assessment":{"changed":false,"description":"This Determination operates within the original scope of the National Health Act 1953, specifically exercising the power in subsection 5D(1) to specify which services qualify as outreach services. It implements the Act's intended function of allowing private health insurance benefits for hospital-substitute care without expanding beyond that original purpose."},"complexity_factors":["Extensive cross-referencing to four sections of the National Health Act 1953 (subsection 4(1), sections 5A, 5C, and 5D)","Deeming provisions that legally treat community-based services as 'hospital treatment' for insurance purposes","Subjective eligibility threshold requiring assessment of whether a service is a 'direct substitute' for hospital care","Distinction between coverage for the outreach service itself versus concurrent professional services rendered by medical practitioners","Nested defined terms including 'applicable benefits arrangement' and 'outreach service'"],"plain_english_summary":"This instrument defines \"outreach services\" as hospital-level medical or nursing care delivered at home or in the community as a direct substitute for hospital or day‑hospital admission. It lets private health insurers pay hospital‑cover benefits for those services.\n\nIt affects private hospital patients, health funds, and treating practitioners by permitting cover for the substitute care and associated doctor services only when they occur as part of the specified outreach program."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-9-2004","history":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-9-2004/history","analysis":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-9-2004/analysis","conflicts":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-9-2004/conflicts","importantCases":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-9-2004/important-cases","documents":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-aos-9-2004/documents"}}