{"id":"F2005L01877","name":"National Health Act 1953 - Determination pursuant to subsection 5D(1) (PSO 5/2005)","slug":"national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-5-2005","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":36072,"registerId":"commonwealth-F2005L01877-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Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can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":2420},"content_quality":"ok","complexity_score":6,"scope_assessment":{"changed":false,"description":"This instrument operates within the established framework of the National Health Act 1953, specifically subsection 5D(1), to define when out-of-hospital care qualifies as insurable hospital treatment. The scope appears consistent with the Act's purpose of regulating applicable benefits arrangements for hospital substitutes."},"complexity_factors":["Multiple interacting statutory provisions requiring cross-referencing (National Health Act 1953 ss 4(1), 5A, 5C, and 5D)","Conditional benefit triggers using 'if and only if' and 'direct substitute' tests","Deeming provisions (outreach services deemed to be 'hospital treatment')","Distinction between coverage rules for facility services versus professional medical services","Reference to 'services specified in this Determination' without the actual schedule of services being provided in the excerpt"],"plain_english_summary":"This determination limits private hospital insurance cover for “outreach services” to care that directly substitutes treatment that would otherwise be provided in a hospital or day‑hospital setting. It also allows payment of a treating doctor’s professional fees when those fees arise during such outreach care.\n\nIt does not let insurers cover routine out‑of‑hospital GP visits. The rule enables hospital‑at‑home programs while preserving the boundary between hospital cover and Medicare primary‑care services."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-5-2005","history":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-5-2005/history","analysis":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-5-2005/analysis","conflicts":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-5-2005/conflicts","importantCases":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-5-2005/important-cases","documents":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-5-2005/documents"}}