Commonwealth legislation

National Health Act 1953 - Determination pursuant to subsection 5D(1) (PSO 2/2006)

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This Act has been repealed and is no longer in force. It is retained for historical reference.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

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This rule tells private health insurers when they can pay benefits for hospital care provided outside actual hospitals — such as nursing care or rehabilitation delivered in your home instead of a hospital ward.

What it allows:

Your insurer can cover "outreach services" (treatments at home or in the community) but only if they replace care you'd otherwise receive as a hospital patient.
It also covers doctor visits that happen while you're receiving these hospital-substitute treatments.

Important limits:

Your insurer cannot use this to cover regular doctor visits or out-of-hospital care that isn't directly replacing a hospital stay.
The service must be a "direct substitute" — meaning you would have been hospitalized if this home-based option didn't exist.

This lets patients recover at home while still accessing their private health insurance benefits, but prevents insurers from paying for general outpatient care under hospital coverage.

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Current sections

Direct links to the current provisions in National Health Act 1953 - Determination pursuant to subsection 5D(1) (PSO 2/2006).

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.

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Current sections

Notes

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