{"id":"F2005L04249","name":"National Health Act 1953 - Determination pursuant to subsection 5D(1) (PSO 12/2005)","slug":"national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-12-2005","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":40442,"registerId":"commonwealth-F2005L04249-current","compilationNumber":null,"startDate":"2026-04-01","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Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can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":2564},"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"This appears to be the original 2005 determination (PSO 12/2005) establishing the outreach services framework under section 5D of the Act, not a subsequent amendment altering the scope of eligible services."},"complexity_factors":["Multiple cross-references to National Health Act 1953 sections 5A, 5C, 5D and subsection 4(1) requiring concurrent reading","Conditional trigger requiring assessment of 'direct substitute for hospital treatment' — a subjective clinical judgment embedded in legislative text","Interaction between deemed hospital treatment (outreach services) and professional services coverage creating overlapping benefit conditions","Nested exceptions: professional services only covered when rendered 'while' outreach services are being provided, creating temporal limitations","Dependent on undefined schedule of specific services not contained in the provided notes text"],"plain_english_summary":"This determination lets private health insurers pay benefits for \"hospital-at-home\" outreach services—care delivered at home or in the community that directly substitutes for an inpatient hospital stay. It also permits payment for medical practitioner (doctor) services provided during those funded outreach treatment sessions, but excludes routine GP or other home visits that aren’t part of a covered outreach treatment."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-12-2005","history":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-12-2005/history","analysis":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-12-2005/analysis","conflicts":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-12-2005/conflicts","importantCases":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-12-2005/important-cases","documents":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-12-2005/documents"}}