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.
Under the Private Health Insurance Act 2007, private health insurers are required to pay benefits for a range of prostheses that are provided as part of an episode of hospital treatment or hospital substitute treatment for which a patient has cover and for which a Medicare benefit is payable for the associated professional service.
The type of products on the Prostheses List include 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.
The Prostheses List contains prostheses and human tissue prostheses and the benefit to be paid by the private health insurers. There are more than 9,000 products on the Prostheses List. With respect to the benefits, there are two categories of prostheses:
No-gap prostheses
No-gap prostheses are listed with a single benefit, and patients will have no out-of-pocket expenses for theses prostheses. For each Medicare Benefit Schedule (MBS) item, it is aimed to have at least one no-gap prosthesis available.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.Patients may incur an out-of-pocket expense for these prostheses, which, at a maximum, will be the difference between the minimum and the maximum benefit.
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
Informed Financial Consent (IFC) - Prostheses and Devices (PDF 55 KB)
Arrangements for listing and setting benefits for prostheses
A ministerially appointed committee called the Prostheses and Devices Committee (PDC) makes recommendations to the Minister for Health and Ageing on the prostheses that should be listed and the benefits payable for them. In making recommendations, the PDC considers advice from Clinical Advisory Groups, members of the Panel of Clinical Experts and the Prostheses and Devices Negotiating Group. Members of these groups are appointed by the PDC.Top of page
The July 2008 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 most current version of the List is known as the July 2008 Prostheses List. The July 2008 Prostheses List has a commencement date of 8 July 2008.The Prostheses List is provided as a Microsoft Access database (for users of Access 97 and 2003 respectively). It is also provided as a Microsoft Word document, a pdf and an Excel spreadsheet.
To access any of the files, right click on the link and select "Save Target As..." to save the compressed file (.zip) to your local drive. You will need a file decompression program such as Winzip to unzip the files. Note: The unzipped file size is over 4 megabytes.
For further information, please refer to Private Health Insurance circular 25/08
PDF Versions
Download the ZIPPED PDF Version of the Prostheses List - Part A (Other 3016 KB)Download the UNZIPPED PDF Version of the Prostheses List - Part A (PDF 4037 KB)
Download the ZIPPED PDF Version of the Human Tissue List - Part B (Other 12 KB)
Download the UNZIPPED PDF Version of the Human Tissue List - Part B (PDF 65 KB)
Access Versions
Link to Access VersionsWord Versions
Link to Word VersionsExcel Versions
Link to Excel VersionsNote: Due to limitations with Excel - cell height cannot be greater than 256 pixels - some cells in the spreadsheet may contain incomplete information. You are advised to reference another version of the Prostheses List if you find incomplete information.
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The February 2009 Prostheses List
The next list to be published after the July 2008 List will be the February 2009 Prostheses List. The following are the key dates for the February 2009 Prostheses List cycle:| 14 July 2008 | Applications accepted Amendment applications and applications for Duplication, Expansion, Compression and Transfer (requiring clinical assessment and/or benefit negotiation) accepted |
| 11 August 2008 | Applications close – including amendment applications and applications for Duplication, Expansion, Compression and Transfer requiring clinical assessment and/or benefit negotiation |
| 22 September 2008 | ARTG cut-off date |
| 19 December 2008 | Close date for duplications/deletions/transfers |
| Mid January 2009 | Invoices for initial listing fees sent to sponsors |
| 8 February 2009 | February 2009 Prostheses List scheduled to be published |
| 22 February 2009 | February 2009 Prostheses List scheduled to commence |
Commencement dates for subsequent Prostheses Lists
From 2009, the scheduled commencement dates for the two Prostheses Lists in each calendar year are 22 February and 15 August.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 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 may be updated prior to the commencement of a cycle 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.
The Prostheses List Guide
current as 27 June 2008Prostheses List Guide Part 1 (PDF 603 KB)
Prostheses List Guide Part 2 (PDF 581 KB)
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Application Forms for the Prostheses List
current as 27 June 2008Application Part A1 - application form (PDF 59 KB)
Application Part A1 - application form (Word 211 KB)
Application Part A2 - Statement in Support (PDF 53 KB)
Application Part A2 - Statement in Support (Word 257 KB)
Application Part B - Cardiac (PDF 374 KB)
Application Part B - Cardiac (Word 378 KB)
Application Part B - Cardiothoracic (PDF 219 KB)
Application Part B - Cardiothoracic (Word 182 KB)
Application Part B - Hip (PDF 262 KB)
Application Part B - Hip (Word 313 KB)
Application Part B - Knee (PDF 280 KB)
Application Part B - Knee (Word 386 KB)
Application Part B - Ophthalmic (PDF 207 KB)
Application Part B - Ophthalmic (Word 254 KB)
Application Part B - Spinal (PDF 446 KB)
Application Part B - Spinal (Word 423 KB)
Application Part B - Urogenital (PDF 265 KB)
Application Part B - Urogenital (Word 292 KB)
Application Part B - Vascular (PDF 79 KB)
Application Part B - Vascular (Word 426 KB)
Application to amend listing (PDF 192 KB)
Application to amend listing (Word 246 KB)
Application to duplicate, compress, expand or transfer billing codes (PDF 201 KB)
Application to duplicate, compress, expand or transfer billing codes (Word 230 KB)
Human Tissue application (PDF 54 KB)
Human Tissue application (Word 171 KB)
Application to amend human tissue listings (PDF 48 KB)
Application to amend human tissue listings (Word 247 KB)
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Prostheses List Application Workshops
Application workshops for the February 2009 Prostheses List were held in Melbourne and Sydney on 3 and 4 July 2008. A copy of the presentation is provided below.Presentation (PDF 765 KB)
Prostheses Cost Recovery
The Private Health Insurance (Prostheses) Rules 2007 and the Private Health Insurance (Prostheses Application and Listing Fee) Rules 2007 supporting the Private Health Insurance Act 2007 became effective 1 April 2007.These Acts and Rules incorporate all of the prostheses reforms that were announced in April 2003 and include the implementation of mandatory cost recovery for the administration of the prostheses arrangements.
Application Fees
Application Fees are payable for each prostheses a sponsor wishes to include in Part A the Prostheses of the Prostheses List. The fee must accompany the application to list. Failure to provide the fee with the application may result in the application being returned without further processing. Failure to provide the correct application fees may result in delays to processing the application.Initial Listing Fees
Initial Listing Fees are payable for new applications to Part A Prostheses of the Prostheses List. Sponsors will be invoiced for these once the Minister has granted their application. 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
Ongoing Listing Fees are invoiced twice a calendar year on two imposition dates - 15 January and 15 July. Sponsors have 28 days in which to pay the ongoing listing fees. These are invoiced for products currently on Part A Prostheses of the Prostheses List, but not for products newly listed on the most recent Prostheses List to the imposition date. Failure to pay the ongoing listing fees will mean that the affected products will become eligible for removal from the next Prostheses List that is made.--------------------------------------------------------------------------------
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Contact details
Director Prostheses Section
PDC and Prostheses List
Robyn BilstonEmail: robyn.bilston@health.gov.au
Phone: 02 6289 9850
Director Prostheses Section
Clinical Assessment and Benefit Negotiation
Kathy HillEmail: kathy.hill@health.gov.au
Phone: 02 6289 1270
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Other relevant information
CircularsOther relevant websites
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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