{"id":"F2006L03281","name":"National Health Act 1953 - Determination pursuant to subsection 5D(1) (PSO 6/2006)","slug":"national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-6-2006","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":60643,"registerId":"commonwealth-F2006L03281-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Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can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":2432},"content_quality":"ok","complexity_score":5,"scope_assessment":{"changed":false,"description":"The determination operates squarely within the delegated authority of subsection 5D(1) of the Act, which specifically empowers the Minister to declare services as outreach services substituting for hospital treatment. It has not expanded beyond this statutory purpose."},"complexity_factors":["Heavy reliance on cross-references to parent Act (sections 4(1), 5A, 5C, and 5D of the National Health Act 1953)","Conditional logic requiring services to be a 'direct substitute' for hospital treatment","Circular deeming provision (outreach services deemed hospital treatment under s 5C, enabling professional services coverage under s 5A)","Distinction between coverage for the specified outreach services versus associated professional services with different limitations"],"plain_english_summary":"This rule lets private health insurers pay hospital-level benefits for specific treatments delivered outside hospitals (home or community) when they genuinely substitute for a hospital stay. It also permits covering medical practitioner services provided alongside those outreach treatments.\n\nIt does not allow insurers to reclassify routine out‑of‑hospital GP or specialist visits as hospital treatment—so ordinary care remains claimable under Medicare or extras, not hospital cover."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-6-2006","history":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-6-2006/history","analysis":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-6-2006/analysis","conflicts":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-6-2006/conflicts","importantCases":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-6-2006/important-cases","documents":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-6-2006/documents"}}