Private Health Insurance - Prostheses List

Formerly known as Schedule 5 - Benefits payable in respect of surgically implanted prostheses, human tissue items and other medical devices list.

Page last updated: 28 March 2014

Prostheses List Advisory Committee
Prostheses List, Guides and Application Forms

Prostheses List

Under the Private Health Insurance Act 2007, private health insurers are required to pay mandatory benefits for a range of prostheses that are provided as part of an episode of hospital treatment (or hospital substitute treatment) where a Medicare benefit is payable for the associated professional service (surgery).

There are more than 9,000 products on the Prostheses List including cardiac pacemakers and defibrillators, cardiac stents, hip and knee replacements and intraocular lenses, as well as human tissues such as human heart valves, corneas, bones (part and whole) and muscle tissue. The List does not include external legs, external breast prostheses, wigs and other such devices, only surgically implanted prostheses.

With respect to the benefits, there are two categories of prostheses:

No-gap Prostheses

No-gap prostheses are listed with a single benefit. Assuming the conditions for the insured patient above are met, health insurers are required to pay this benefit.

Gap-permitted Prostheses

Gap-permitted prostheses have both a minimum and maximum benefit listed. For these prostheses private health insurers are required to pay at least the minimum benefit.
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Informed Financial Consent

Clinical choice remains a matter between the doctor and the patient. If a doctor considers that a gap-permitted prosthesis is the most clinically suitable for a patient, the doctor should provide appropriate clinical and financial information so that the patient may give informed financial consent before the procedure proceeds.
Private Health Industry Agreed Guidelines:
Download the PDF version of the Informed Financial Consent (IFC) - Prostheses and Devices Guidelines (PDF 55 KB)
Download the Word version of the Informed Financial Consent (IFC) - Prostheses and Devices Guidelines (Word 19 KB)

Arrangements for Listing and Setting Benefits for Prostheses

A Ministerially appointed committee called the Prostheses List Advisory Committee (PLAC) makes recommendations to the Minister for Health and Ageing on the prostheses that should be listed and the benefits insurers should pay for them. In making recommendations, the PLAC considers advice from Clinical Advisory Groups, members of the Panel of Clinical Experts and the Negotiating Oversight Committee.

Further information and PLAC Bulletins
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The February 2014 Prostheses List

The Prostheses List, which lists the no-gap and gap-permitted prostheses and the benefits payable for them is released twice per year. The February 2014 Prostheses List commences on 28 February 2014.

The Prostheses List is provided as a Microsoft Access database. It is also provided in PDF and Excel format.

Download the Current Prostheses List

Prostheses List Information Sessions

The Department of Health and Ageing held three information sessions in July 2012.

Download the PDF version of the July 2012 presentation (PDF 177 KB)
Download the PowerPoint version of the July 2012 presentation (Other 255 KB)

Key Dates for the February 2014 Prostheses List

September/October 2013CAG meetings
12 September 2013Prostheses List Advisory Committee Meeting
17 September 2013Ongoing listing fee invoices for August 2013 Prostheses List to be sent (invoice payable within 28 days)
9 October 2013Prostheses List Advisory Committee Meeting
November 2013CAG meetings
7 November 2013Prostheses List Advisory Committee Meeting
4 December 2013Prostheses List Advisory Committee Meeting
22 January 2014ARTG and MBS item numbers required for recommended new applications for the February 2014 Prostheses List
14 February 2014February 2014 Prostheses List scheduled to be released
28 February 2014February 2014 Prostheses List scheduled to commence
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The Prostheses List Guide and Application Forms

The Prostheses List guide to listing and setting benefits for prostheses (the Guide) consists of two parts:
  • Part 1 – Understanding the Prostheses Arrangements; and
  • Part 2 – Making an application for inclusion in the Prostheses List.
Part 1 provides information on the prostheses arrangements including references to the new legislation, mandatory fees, the application cycle processes, explains the clinical assessment of products and the evidence required to demonstrate their clinical effectiveness.

Part 2 provides a detailed explanation of how to assemble and present an application to list a product on the Prostheses List, the information it should include and the evidence required to support it.

All sponsors are encouraged to use the Guide, and should be aware that it will be updated from time to time to ensure that the information it contains is current.
Note: 1. The Guide does not address the requirements for Human Tissue items. Please contact the Prostheses Section for further information on Human Tissue items - contact details below.
Download the Prostheses Guide and Application forms

Prostheses Cost Recovery

The Private Health Insurance Act 2007 (“the Act”) came into effect on 1 April 2007. It includes provisions relating to prostheses that are intended to replace the provisions relating to prostheses previously contained in the National Health Act 1953 (as amended by the National Health Amendment (Prostheses) Act 2005).

Prostheses List: Cost Recovery Impact Statement

The Prostheses List arrangements are set out in Division 72 of the Act and the Private Health Insurance (Prostheses) Rules (“the Rules”).

Mandatory cost recovery arrangements, which were introduced in the new legislation, are set out in the Private Health Insurance (Prostheses Application and Listing Fees) Act 2007 and the Private Health Insurance (Prostheses Application and Listing Fee) Rules.

Application Fees

An Application Fee of $600 must accompany each Application to list a new product on Part A of the List. Failure to provide the correct fee with the application will result in the application being returned without further processing.

Initial Listing Fees

An Initial Listing Fee of $200 is payable for each new listing to Part A of the Prostheses List. Sponsors will be invoiced for these once the Minister has granted their application. This fee is applicable for New Applications. The initial listing fees are payable within 14 calendar days of being invoiced. Failure to pay the initial listing fee will result in the new application not being included in the Prostheses List.

Ongoing Listing Fees

An Ongoing Listing Fee of $200 is payable for all items that are continuing from the previous list excluding those that were newly listed on the most recent List to the imposition date. This fee is invoiced twice a calendar year on two imposition dates - 15 March and 15 September. Sponsors have 28 days in which to pay the ongoing listing fees. Failure to pay the ongoing listing fees will mean that the affected product(s) will become eligible for removal from the following Prostheses List.

Human Tissue Review

The Commonwealth Department of Health and Ageing is conducting a review of Part B Human Tissue of the Prostheses List.

In October 2007, Robert Doyle completed his Review of the Prostheses Listing Arrangements (Doyle Report). Recommendation 15 of this report, which the Government agreed to, is as follows:
In relation to human tissue:
  • The Department of Health and Ageing should carry out a comprehensive review of existing benefits for human tissue items, informed by cost-accounting data provided by tissue banks, by June 2010.
  • The Department should ensure it has appropriate clinical expertise available to provide advice to the Minister on the listing of human tissue items.
  • In providing advice on items for inclusion on the List and benefit levels, the Department should have regard to the principles that no profit should be derived from trade in human tissue and items involving autologous tissue should not be listed.
The Human Tissue Review is the first step in addressing recommendation 15 of the Doyle Report.

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Contact details for the Prostheses Section

Director Prostheses Section
Prostheses Clinical Assessment and List Management Team

Lyndall Moore
Email: Lyndall Moore
or
Phone: 02 6289 9152

Director Prostheses Section
Prostheses Clinical Advisory Groups and Human Tissue Team

Megan Parrish
Email: Megan Parrish
or
Phone: 02 6289 8512

Other relevant information

Publications

Circulars

Other Relevant Websites

Health Technology Assessment (HTA) website

The Department has developed a new website which provides a comprehensive overview of current Australian Government HTA processes used to inform decisions about the registration of health technologies for use in Australia and the reimbursement of these technologies provided under various funding programs, including the Medicare Benefits Schedule, Pharmaceutical Benefits Scheme and the Prostheses List.

The website is part of the Australian Government's response to the December 2009 Review of Health Technology Assessment in Australia (HTA Review) and arose from stakeholders identifying the need to have comprehensive information about Australian Government HTA processes available in one central point in an easy to use format.

The website also provides a portal to the HTA Access Point which will assist potential applicants seeking assessment of codependent and hybrid technologies.

Access the new Australian Government HTA website.

Therapeutic Goods Administration (TGA)
Medical Services Advisory Committee (MSAC)
Consumer information

Industry links

Australian Health Insurance Association (AHIA)
Australian Private Hospitals Association (APHA)
Catholic Health Australia (CHA)
Medical Technology Association of Australia (MTAA)
Australian Medical Association (AMA)

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Download Links
Use the links below to help navigate your way to the downloadable documents of the Prostheses List.

>> Prostheses Application Forms
>> Human Tissue Application Forms
>> Prostheses List Guide Part 1
>> Prostheses List Guide Part 2
>> The Prostheses List
>> The Human Tissue List

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