Prostheses cover under private health insurance

A prosthesis is an artificial substitute for a missing body part. Prostheses can be cosmetic, functional or both. Some prostheses are applied outside the body, like artificial limbs or cosmetic prostheses. Some are implanted or applied surgically like artificial hip joints or heart valves.

The prostheses list

By law, your private health insurer must pay a benefit for a prosthesis if:

  • the prosthesis is on the prostheses list
  • the prosthesis is being surgically applied or implanted
  • you have cover for the treatment

The list shows the minimum benefit insurers must pay for listed prostheses.

We publish the prostheses list twice a year.

What prostheses are listed

There are more than 10,000 surgically implanted or applied prostheses on the list, including:

  • joint replacements like hips and knees
  • pacemakers and other implantable electronic cardiac devices
  • vascular and cardiac stents
  • human tissue items like bones or bone fragments, vascular grafts, corneas and heart valves

What prostheses are not listed

External and cosmetic prostheses are not covered on the list. This includes:

  • prosthetic limbs
  • external breast prostheses
  • cosmetic implants

Out of pocket costs for prostheses

You won’t pay any out of pocket costs for a prosthesis if the minimum benefit shown on the prostheses list covers its cost. Your insurer must pay this.

If the minimum benefit is less than the cost of the prosthesis you might have to pay the difference.

Before you have a prosthesis surgically implanted or applied, 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

We publish the current prostheses list twice a year. Health insurers use the 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.

Reforming access to prostheses

As part of wider reforms, the Australian Government and the Medical Technology Association of Australia agreed to rebalance the costs of medical devices for privately insured consumers.

Learn more about reviews and reforms.

Ask us add a prosthesis to the list

If you are a prosthetic device sponsor, you can apply to change or add a prosthesis to the list

Last updated: 
19 February 2020

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