PHI 13/23 – Private Health Insurance (Prostheses) Rules (No. 1) 2023

The Private Health Insurance (Prostheses) Rules (No. 1) 2023 will commence on 1 March 2023.

Date published:
PHI circular type:
Prostheses announcement
Health sector

This circular provides information for stakeholders about the March 2023 Prostheses List.

The delegate of the Minister for Health and Aged Care has made the Private Health Insurance (Prostheses) Rules (No. 1) 2023, to replace the Private Health Insurance (Prostheses) Rules (No. 3) 2022.

The Private Health Insurance (Prostheses) Rules (No. 1) 2023 were registered on the Federal Register of Legislation on 15 February 2023 and will commence on 1 March 2023.

The changes effected in the Rules

The Private Health Insurance (Prostheses) Rules (No. 1) 2023 (the Prostheses Rules) give effect to all changes resulted from completion of the Prostheses List applications (new, amendment, deletion and sponsors’ transfers).

Other changes

Reducing benefits for Part D billing codes

The billing codes for the general use items are listed on Part D of the Prostheses List. As part of the Prostheses List reforms announced in the 2021-22 Budget, the Prostheses List benefits are set up to be reduced in 3 instalments (in 2022, 2023, and 2024), with the reduction commenced in July 2022 Prostheses List. The March 2023 Prostheses List is the previously announced deadline for reducing the benefits for all general use items by 40 percent of the difference between the Prostheses List benefits and the Weighted Average Prices, estimated by the Independent Health and Aged Care Pricing Authority (IHACPA).

Final changes to Part D

There are some billing codes for which the PL Part D had to be corrected to rectify some inconsistencies.

Specifically, two groups in the Neurosurgical - DURA DEFECT REPAIR 04.02.07 and 04.02.08 for the small and medium size Dura Self-Adhesive Membrane have been retained on Part A, consistently with listing of group 04.02.09 for the large Dura Self-Adhesive Membrane, and groups for the Dura Grafts Membrane of different sizes [04.02.01, 04.02.02, 04.02.03, and 04.02.04].

The billing codes listed in sub-groups - PULMONARY/PERITONEAL DEVICES - Drainage Catheters – Pleural and - PULMONARY/PERITONEAL DEVICES - Drainage Catheters - Para/Thoraceulesis, have been moved from Part A to Part D, consistently with the previous advice provided by the Clinical Implementation Reference Group (CIRG).

Reduction of benefits for metal backed patellas

The Department undertook the PL post-listing review of metal-backed patellas and following consideration of the review findings, the benefits for groups 12.08.02 – Knee–PATELLAR COMPONENT–Cemented, Polyethylene, Metal Backed and 12.08.03 – Knee–PATELLAR COMPONENT–Uncemented, Polyethylene, Metal Backed have been reduced to the same benefit payable for all-poly patellas listed in sub-group 12.08.01 - Cemented, All Polyethylene, benefit $431.

Removal of microcatheters from Prostheses List Part A.

As previously advised in Private Health Insurance circular PHI 69/22, the billing codes for microcatheters listed in the subgroups – Neurosurgical - NEURO INTERVENTION – Catheters and – Vascular - Occlusion Devices - Delivery Device for Occlusion Media – Catheter, are deleted from the Prostheses List with effect on 1 March 2023.

The Prostheses List (Part A, Part B, Part C and Part D) and reports on changes are provided in Excel and Portable Document Format at Prostheses List | Australian Government Department of Health and Aged Care.