Prostheses cover under private health insurance

Private health insurers are required to pay benefits for products listed on the Prostheses List, if the product is provided to the patient with the right cover as part of hospital or hospital substitute treatment. Read more about what products are listed and benefits.

Prostheses list

The Private Health Insurance (Prostheses) Rules is a legislative instrument made under the Private Health Insurance Act 2007.  Schedule of the Private Health Insurance (Prostheses) Rules is known as the Prostheses List.

Private health insurer are required to pay a benefit for a product if:

  • the product is listed on the Prostheses List
  • you receive the product as part of the hospital or hospital substitute treatment
  • you have appropriate health insurance to cover the treatment
  • a Medicare benefit is payable for a service associated with the use of the product.

The Prostheses List shows the minimum benefits insurers are required to pay for listed products.

We publish the Prostheses List minimum 3 times per year.

What products are listed

Products currently listed on the Prostheses List include surgically implanted medical devices, devices designed and essential for implantation or for maintaining the implant, human tissue items and other specified devices.

There are more than 11,000 products listed on the Prostheses List, including:

  • hip, knee or shoulder joint replacement devices
  • cardiac implantable electronic devices, like pacemakers and implantable cardioverter defibrillators
  • vascular and cardiac stents
  • human tissue items like bone or bone fragments, vascular grafts, corneas and heart valves
  • insulin infusion pumps
  • cardiac ablation catheters
  • cardiac remote monitoring systems.

What products are not listed

Products not eligible to be listed on the Prostheses List include:

  • external prostheses, like prosthetic limbs or external breast prostheses
  • surgically implanted devices, not purposely designed for replacing an anatomical body part, or combat a pathological or modulate a physiological process, such as some cosmetic implants
  • devices intended to be used for diagnostic purposes.

Out of pocket costs for products listed on the Prostheses List

If you have an appropriate cover, and the product listed on the Prostheses List was provided to you, or used during procedure, or implanted into your body as part of your hospital treatment, you should not have any out of pocket costs.

But if the minimum benefit set up on the Prostheses List is less than the cost of the product, you might have to pay the difference.

Before you have your treatment, discuss the cost and your cover with:

  • your health insurer
  • your treating doctor
  • the hospital you will be treated at.

Read more about out of pocket costs.

The Prostheses List for insurers and others

Private hospitals and health insurers use the Prostheses List to keep their claims and payments systems up to date.

For updates on prostheses reforms and other matters related to private health insurance see our private health insurance circulars.

Prostheses List reforms

As part of wider reforms, the Australian Government and the Medical Technology Association of Australia agreed to consider changes to the Prostheses List arrangements to support better access to medical technology.

Learn more about Prostheses List reviews and reforms.

Considering the impact of COVID-19, the Minister for Health, the Hon Greg Hunt MP, has agreed to pause all Prostheses List reviews and all reform work under the Strategic Agreement with Medical Technology Association of Australia, starting from 1 April 2020.

How to list a product on the Prostheses List

If you have products that meet the criteria, you can apply to list or change products on the Prostheses List

Last updated: 
22 October 2020

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