{"id":"F2007L00253","name":"National Health Act 1953 - Determination pursuant to subsection 5D(1) (PSO 1/2007)","slug":"national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-1-2007","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":68566,"registerId":"commonwealth-F2007L00253-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Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can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":1834},"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"This is the original 2007 determination establishing the outreach services framework under section 5D of the Act. It does not represent a scope expansion beyond the original legislative intent, but rather specifies the services eligible under the existing statutory scheme for hospital substitute treatment."},"complexity_factors":["Cross-references to four separate sections of the National Health Act 1953 (ss 4(1), 5A, 5C, 5D)","Conditional eligibility framework requiring services to be 'direct substitutes' for hospital treatment","Interaction between three distinct legal concepts: 'outreach services', 'hospital treatment', and 'professional services'","Deeming provision where outreach services are statutorily treated as hospital treatment for insurance purposes","Distinction between coverage for the outreach service itself versus medical practitioner services rendered concurrently"],"plain_english_summary":"This Determination says private hospital cover can apply to certain medical care delivered outside hospitals when that care directly substitutes for an admitted hospital stay — for example, home chemotherapy or rehab provided instead of a hospital bed. Associated doctor visits during such outreach may also be claimed under hospital cover. It does not expand hospital benefits to routine GP or outpatient care that aren’t true substitutes for admission, preventing coverage gaps for community‑based hospital‑level care."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-1-2007","history":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-1-2007/history","analysis":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-1-2007/analysis","conflicts":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-1-2007/conflicts","importantCases":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-1-2007/important-cases","documents":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-1-2007/documents"}}