{"id":"F2006L01988","name":"National Health Act 1953 - Determination pursuant to subsection 5D(1) (PSO 3/2006)","slug":"national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-3-2006","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":117370,"registerId":"commonwealth-F2006L01988-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Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can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":2008},"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"The Determination appears focused on its original purpose under subsection 5D(1): specifying which services qualify as hospital-substitute outreach services for private health insurance benefits. The notes indicate a tight scope limited to direct hospital replacements and associated medical care."},"complexity_factors":["Cross-references to four separate sections of the National Health Act 1953 (sections 4(1), 5A, 5C, and 5D)","Conditional eligibility requiring services to be 'direct substitutes' for hospital treatment","Interaction between two distinct benefit categories: outreach services and concurrent professional services","Statutory deeming provision treating out-of-hospital care as 'hospital treatment' for insurance purposes","Delegated legislative instrument operating within primary Act definitions"],"plain_english_summary":"This Determination tells private health insurers when they may pay benefits for treatment delivered outside hospitals: only for \"outreach services\" that directly substitute for care that would otherwise require hospital admission. It also permits insurers to cover medical practitioner visits that occur as part of that hospital-substitute care.\n\nIt affects patients in hospital‑at‑home programs, insurers setting coverage, and clinicians providing outreach services, while barring benefit payments for routine outpatient care."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-3-2006","history":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-3-2006/history","analysis":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-3-2006/analysis","conflicts":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-3-2006/conflicts","importantCases":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-3-2006/important-cases","documents":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-3-2006/documents"}}