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Prostheses is the plural form of prosthesis, or an artificial body part. Examples include anything from an artificial leg to an artificial heart to metal screws and plates that reinforce the skeleton.
If your prosthesis is part of a Medicare-approved treatment, the device is included in your Medicare cover automatically. For example, if you're getting a hip replacement, the cost of the artificial hip is covered in addition to the surgery itself.
Prostheses are generally funded in the following ways:
You won't be covered for prostheses if it's for cosmetic purposes only. For example, the public system won't cover breast implants unless it's to reconstruct your breasts after a mastectomy.
Yes. Just like Medicare, your private hospital insurance will cover the cost of your prosthesis as long as it forms part of a treatment listed on your policy and is considered medically necessary.
There are a few benefits to using private cover for prostheses:
The Prostheses List is the Australian government's official list of more than 11,000 surgically implanted prostheses and other devices required for the implants to function.
It's basically a list of vetted products, down to the brand and model number in some cases. If your private health insurance covers a particular treatment requiring prostheses, your private doctor must use a device on this list and your insurer must reimburse you the minimum benefit amount, which is also included in this official list.
The government updates the list three times a year to keep up with the never-ending improvements in medical technology. Having a regularly updated list of properly vetted devices helps keep insurance costs down since it reduces the chance of follow-up surgery due to malfunction.
Items on the Prostheses List are broken up into several categories:
The latest version of the Prostheses List is available from the Department of Health website.
With health insurance, you'll be covered for prostheses based on the type of treatment rather than whether or not a prosthesis is involved. For example, if your policy covers heart surgery but not hip replacements, you'll be covered for a pacemaker but not an artificial hip.
Health insurance can be broken into 4 tiers: Gold, Silver, Bronze and Basic. The level you choose will determine what treatments you are covered for and therefore what prostheses are covered.
Here are examples of some treatments you'll find at each level and an example of a prosthesis that's included:
Most devices on the Prostheses List are considered no-gap prostheses, meaning your insurer has to cover the full cost of the device. There are some gap-permitted prostheses you can be charged for, but for every gap-permitted device, there is an equivalent no-gap device also on the list. Feel free to ask your doctor to use the no-gap version if you are concerned about cost.
The gap-permitted items on the list will have an amount listed in the maximum benefits column in addition to the minimum benefits column. If the maximum benefits column is blank, it is a no-gap prosthesis and you won't be charged any extra for it.
With private health insurance, you usually won't pay out-of-pocket for the device itself but you may see some out-of-pocket charges related to the surgery.
When you use private health insurance in a private hospital, Medicare and your insurer team up to pay the Medicare Schedule Fee for that treatment (ie, what Medicare alone would have paid had you gone public).
But private doctors are free to set their own prices leaving you responsible for any difference. This is called your gap. The good news is you can avoid some or even all of this gap if your insurer offers an Access Gap Cover scheme in which certain doctors agree to lower their prices for the fund's members.
The phrase health appliance is a catch-all term that includes artificial body parts like prostheses but also includes sensory aids like eyeglasses and medical devices such as blood pressure monitors. Unlike prostheses, these other appliances support rather than replace body parts.
Health Appliances = Prostheses + Sensory Aids + Medical Devices
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