{"id":"F2006L04188","name":"National Health Act 1953 - Determination pursuant to subsection 5D(1) (PSO 8/2006)","slug":"national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-8-2006","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":61160,"registerId":"commonwealth-F2006L04188-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Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can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":2354},"content_quality":"ok","complexity_score":5,"scope_assessment":{"changed":false,"description":"The determination operates within the specific scope of subsection 5D(1) of the National Health Act 1953, which authorises the Minister to declare services to be hospital treatment for private health insurance purposes. The instrument appears to be functioning as originally intended—to specify medical services that substitute for inpatient care."},"complexity_factors":["Multiple cross-references to the National Health Act 1953 (sections 4(1), 5A, 5C, and 5D)","Technical defined terms requiring interpretation ('outreach service', 'applicable benefits arrangement', 'day hospital facility')","Conditional eligibility logic ('if and only if', 'so long as', 'direct substitute')","Distinction between the outreach services themselves and professional services rendered concurrently","Nested conditions: professional services coverage depends on both the determination's scope and the concurrent provision of outreach services"],"plain_english_summary":"This instrument tells private insurers when out-of-hospital care can be paid under hospital cover. It lists outreach treatments that count as hospital treatment when they directly substitute for inpatient or day‑patient care and allows associated medical practitioner services during those treatments. It expands hospital cover beyond hospitals—but only where the service genuinely replaces hospital care; routine doctor visits and other non‑substitutive outpatient care remain excluded."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-8-2006","history":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-8-2006/history","analysis":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-8-2006/analysis","conflicts":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-8-2006/conflicts","importantCases":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-8-2006/important-cases","documents":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-8-2006/documents"}}