Does health insurance cover prostheses? Compare cover options from Australian funds.
Private health insurance provides cover for an extensive range of medical procedures and conditions, including prosthetics. If you’re undergoing surgery to have a prosthesis implanted or applied, and if you have private health insurance with the necessary cover, you can receive some much-needed financial assistance.
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Private health insurance and prostheses
As soon as you find out that you will be undergoing surgery to apply or implant a prosthesis, get in touch with your private health insurer. You’ll need to check with your fund to find out whether you will be covered for the cost of the surgery.
Certain treatments such as joint replacement therapy are commonly restricted or excluded on many policies, so it’s worth reading the fine print of your policy documents and contacting the insurer directly if you have any questions. If your surgery is excluded, you won’t receive any cover. If restricted cover is available, you’ll receive a private health insurance benefit for the prosthesis but you may only receive limited cover for other aspects of your treatment and for your stay in hospital.
It’s also essential that you consult with your treating doctor and find out whether the prosthesis you will receive is included on the Prostheses List. If it’s not, check with your doctor to see if there is a prosthesis included on the list that may be able to be used.
Next, check with the hospital for details about the cost of the procedure, the cost of your hospital accommodation and any other out-of-pocket expenses you may have. You can then compare the costs with the benefits available from your policy and work out how much will be covered by your insurer and how much you will have to pay.
What is the Prostheses List?
The Prostheses List is a list of more than 10,000 surgically implanted prostheses, human tissue items and other medical devices. Private health insurers must pay a benefit for the items on the list when they are provided to a patient with the appropriate private health insurance cover in place, and the Prostheses List details the minimum benefit amount payable for each individual item.
The list is updated twice each year and under Australian law, private health insurers must pay at least the minimum benefit listed for each item.
What items are on the Prostheses List?
The types of surgically implanted prostheses, human tissue items and other medical devices on the Prostheses List are broken up into several cover areas including:
- Ear, nose and throat
- General/miscellaneous products (prostheses not included in other categories)
- Plastic and reconstructive
- Specialist orthopaedic
The latest version of the Prostheses List is available from the Department of Health website.
Do Australian health funds provide health insurance for prostheses?
What isn’t listed on the Prostheses List?
Each item must satisfy a range of criteria in order to be included on the list, such as being entered on the Australian Register of Therapeutic Goods. Items such as external limb prostheses, external breast prostheses and implants used solely for cosmetic purposes are not included on the Prostheses List.
Out-of-pocket expense for a prosthesis
Whether or not you will have any out-of-pocket expenses will depend on the level of private health cover you have and the prosthesis you receive. If the minimum benefit outlined on the Prostheses List covers the cost of the procedure to the hospital, you won’t have to pay for any expenses out of your own pocket.
But if the minimum benefit isn’t enough to cover the full cost of the prosthesis to the hospital, you might need to cover all or a portion of the ‘gap’ between the minimum benefit payable and the total cost of the prosthesis - this will depend on the hospital where the procedure is performed.
What do I do if my insurer won’t pay?
If your private health insurer refuses your claim for a prosthesis, you are well within your rights to ask for an explanation why. If your claim was refused because the surgically implanted prosthesis, human tissue item or medical device you received was not included on the Prostheses List, the insurer is not required by law to pay a benefit.
However, you could ask the insurer to pay the claim on an ex gratia basis (out of kindness rather than due to any legal requirement), although this is entirely up to their discretion.
Are there no-gap options for prothesis?
A no-gap prosthesis is an item included in the Prostheses List that has no maximum benefit listed. Instead, only a minimum benefit is listed, meaning that patients will not have to cover any out-of-pocket expenses when they have surgery to apply or implant this prosthesis.
Private health insurers are required by Australian law to pay this benefit. There is generally at least one no-gap prosthesis option available for each Medicare Benefit Schedule item.
Compare your cover options with the aid of an adviser
If you need to undergo surgery to receive a prosthesis, make sure you check to see if the device you will receive is included on the Prostheses List, and whether cover is provided by your private health insurance. With the right cover in place, you can receive much-needed financial assistance to cover the cost of your important medical procedure.