Evaluation of the National External Breast Prostheses Reimbursement Program

1. Introduction

Page last updated: 05 November 2010

1.1 Overview of the program

The National External Breast Prostheses Reimbursement Program was announced by the Commonwealth Government in May 2008, and has been operating since December 2008. The aims of the project are to:
  • provide financial reimbursement of up to $400 per external breast prosthesis for women who have undergone a full or partial mastectomy as a result of breast cancer
  • ensure national consistency in the provision of support towards the cost of breast prostheses
  • improve the quality of life of women who have undergone a full or partial mastectomy as a result of breast cancer.
The program is being administered by Medicare Australia on behalf of the department under the terms of a service arrangement and business rules, with a business practice agreement to be signed in late 2009.

Women claiming reimbursement through Medicare can do so by downloading and completing a claim form from the Medicare website, going to a Medicare branch for a hard copy, or calling Medicare. Those receiving financial assistance from the Department of Veterans' Affairs (DVA) are able to claim their entitlement through DVA.

1.1.1 Administration matters and reporting

Medicare is required to provide monthly and end-of-financial year statistics to the department on a number of items identified on the program claim form, including: the number of reimbursements, amount reimbursed, demographic data and process performance. Medicare is required to process 90% of all claims within ten days of lodgement, as part of its obligations as administrator of the program.

Under the service arrangement, the department is obliged to provide policy advice to Medicare in a timely manner and to respond to queries and complaints that relate to policy issues under the program.

1.2 Eligibility criteria for women receiving the reimbursement

Whilst the program has been in operation since December 2008, eligible women are able to submit claims from 1 July 2008. There are no time limits applied to when the mastectomy occurred, but there are time limits as to when prostheses may be claimed.

Other specific eligibility criteria include:
  • recipients need to have had a mastectomy as a result of breast cancer
  • recipients need to be permanent residents of Australia and have current Medicare entitlements
  • women are eligible if they have not received financial assistance for the prosthesis from a private health insurer, state or territory government or other organisation; or have received a refund or financial assistance through their private health insurer, state or territory government or other organisation less than the maximum Commonwealth reimbursement
  • eligible women can claim up to $400 reimbursement for new and replacement external breast prostheses
  • if a claim under the program has been made, a subsequent reimbursement can be claimed no earlier than two years from the date of last purchase.