{"id":"F2005L00594","name":"National Health Act 1953 - Determination pursuant to subsection 5D(1) (PSO 2/2005)","slug":"national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-2-2005","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":112848,"registerId":"commonwealth-F2005L00594-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Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can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":2269},"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"This determination operates within the original scope of the National Health Act 1953, specifically exercising the power under section 5D(1) to specify services that can be treated as hospital treatment when provided as outreach services. It implements the legislative framework for hospital-substitute treatment without expanding beyond the Act's original intent."},"complexity_factors":["Multiple cross-references to sections of the National Health Act 1953 (ss 4, 5A, 5C, 5D)","Conceptual complexity involving 'deemed' hospital treatment and 'direct substitute' requirements","Conditional logic requiring services to be substitutes for hospital care (if-and-only-if conditions)","Technical terminology including 'applicable benefits arrangement' and 'outreach service'","The excerpt provided contains explanatory notes but not the actual schedule of specified services"],"plain_english_summary":"This determination lets private health insurers treat specified outreach services—care delivered outside hospitals (e.g., at home or clinics)—as if they were hospital treatment, so hospital cover can pay where those services substitute for inpatient or day-surgery care.  \n\nDoctors’ fees are also payable under hospital cover when the practitioner treats you in connection with those outreach services. It affects insurers, clinicians providing hospital-substitute care, and patients with hospital cover receiving out-of-hospital treatment."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-2-2005","history":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-2-2005/history","analysis":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-2-2005/analysis","conflicts":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-2-2005/conflicts","importantCases":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-2-2005/important-cases","documents":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-2-2005/documents"}}