Commonwealth legislation

Determination pursuant to subsection 5D(1) (PSO 3/2005)

RepealedCTH

This Act has been repealed and is no longer in force. It is retained for historical reference.

Jurisdiction

Commonwealth

Collection

legislative instrument

Plain English Summary

4/10 complexity

This determination tells private health insurers which out-of-hospital treatments qualify as "outreach services" that can be paid under hospital cover (rather than extras), and that doctors’ visits tied to those outreach treatments are also covered. It affects insurers, hospitals, practitioners and patients receiving hospital-equivalent care outside inpatient settings.

Insurers may only pay when the service is on the official list and truly substitutes for hospital care — ordinary GP or routine out‑of‑hospital visits remain excluded.

JSON API

Deep dive

Want the full deep dive?

Zoe can write the in-depth analysis on top of the summary above: how it works, who it affects and what each part actually does.

Current sections

Direct links to the current provisions in Determination pursuant to subsection 5D(1) (PSO 3/2005).

Notes

Note 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).

Note 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.

Source text

Sourced from the Federal Register of Legislation (legislation.gov.au), CC BY 4.0.

Deep dive

Current sections

Notes

Notes

Source text

Notes Notes

Notes