{"id":"F2005L03032","name":"National Health Act 1953 - Determination pursuant to subsection 5D(1) (PSO 9/2005)","slug":"national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-9-2005","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":37948,"registerId":"commonwealth-F2005L03032-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Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Notes","sectionType":"part","heading":"Notes","content":"# Notes\n\nNote 1: Health funds can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":2349},"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"The determination implements the original statutory intent of section 5D by establishing which specific hospital-substitute treatments qualify for hospital cover benefits. There is no indication of scope expansion beyond the original purpose of deeming specified outreach services as hospital treatment."},"complexity_factors":["Multiple cross-references to parent Act sections (4(1), 5A, 5C, 5D) requiring simultaneous interpretation","Conditional 'direct substitute for hospital treatment' test creating subjective eligibility thresholds","Deeming provision (outreach services deemed hospital treatment) creates legal fiction requiring statutory interpretation","Distinction between the outreach service coverage and concurrent professional services coverage","Reliance on undefined parent Act terminology ('applicable benefits arrangement')"],"plain_english_summary":"This determination lets private health insurers treat specified outreach services delivered outside hospitals as hospital treatment under the National Health Act, so those services can be claimed under hospital cover (not extras). It affects patients receiving home-based substitutes for inpatient care (e.g., home dialysis, chemotherapy, hospital-in-the-home) and allows associated doctor fees to be claimed when provided concurrently with the outreach service. Routine out-of-hospital care or separate GP visits remain excluded."}},"importantCases":[],"_links":{"self":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-9-2005","history":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-9-2005/history","analysis":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-9-2005/analysis","conflicts":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-9-2005/conflicts","importantCases":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-9-2005/important-cases","documents":"/api/acts/national-health-act-1953-determination-pursuant-to-subsection-5d-1-pso-9-2005/documents"}}