Health insurance for prostheses

Health insurance for prostheses: how Australian health funds cover you

Fund	Prostheses conditions	More info
	Except for excluded services, ahm will cover you up to the minimum benefit listed on the Government's Prostheses List.	Go to site
	Government approved, non-cosmetic prostheses that have been surgically implanted are covered by your HCF hospital product.	Go to site
	Government approved prosthetic devices.	Read review
	Government approved prosthetic devices.	Read review
	Government approved prosthetic devices.	Read review
	Australian Unity will cover the minimum cost for government approved surgically implanted items. Non-admitted prosthesis requests are subject to prior application and approval.	Read review
	If you're planning on claiming for appliances, blood glucose monitor, extremity pump, GMHBA approved orthopaedic appliances, nebuliser pump,non surgical prostheses, pressure garments, sleep apnoea monitor or tens monitor, you'll require a doctor's letter of recommendation.	Read review
	Government approved, non-cosmetic prostheses that have been surgically implanted are covered by the fund.

What are prostheses?

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.

How are prostheses covered by Medicare?

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:

• Your state's public health system. Many states cover artificial limbs as long a doctor refers you, you're a resident of the state and you have a valid Medicare card.
• Department of Veteran Affairs. If you lost your limb while serving or you have a Gold Card, you will be eligible for cover through the Department of Veteran Affairs.
• The National Disability Insurance Scheme (NDIS). Many amputations are due to medical conditions like diabetes. If that's the case, you may be eligible for prostheses through the NDIS.

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.

Does private health insurance cover prostheses?

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:

• You skip the waiting lists. If your treatment isn't urgent, Medicare will make you wait for your treatment. Private insurance can let you skip the queue so you can get the treatment you need sooner. If you need a shoulder replacement and are in constant pain, you probably don't want to wait too long to get it fixed.
• You get to choose your doctor. With Medicare, you have to use who they tell you to use. Private insurance lets you choose the doctor you're most comfortable with.
• You can get extra physio. Medicare will cover in-hospital physio but often won't cover outpatient treatment. Some extras policies will cover outpatient physio, which is important if you need to regain your range of motion following an implant.

What is the Prostheses List?

The Prostheses List - renamed the Prescribed List of Medical Devices and Human Tissue Products on 1 July 2023 - 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.

What items are on the Prostheses List?

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.

How to find health insurance for prostheses

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:

• Basic. Insurers can offer any of the other 35 clinical categories at Basic, but only on a restricted basis. A restricted benefit means you're covered as a private patient in a public hospital and could face significant expenses in a private hospital. However, in most cases, there will be no cover for any treatments that would require a prosthesis.
• Bronze. Offers bone, joint and muscle cover (bone screws) and medically necessary breast surgery (reconstructive breast implants following mastectomy).
• Silver. Offers all of the above plus heart and vascular system cover (pacemaker); back, spine and neck cover (vertebrae replacement) and hearing implant cover (middle ear implant)
• Gold. All of the above plus joint replacement cover (artificial hip) and insulin pump cover (insulin pump cover is separate from diabetes cover).

What is a no-gap prosthesis?

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.

Are there out-of-pocket expenses for prostheses?

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.

What is the difference between a prosthesis and a health appliance?

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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Frequently asked questions

• What are the waiting periods for prostheses cover?

  Standard private health insurance waiting periods apply for treatments involving prostheses. Generally, you will need to serve a 2 month waiting period for most hospital treatments or 12 months for pre-existing conditions. For more complex treatments such as joint replacements or cataract surgery, the waiting period is typically 12 months. Always check with your health fund for the specific waiting periods that apply to your policy and planned treatment.

• Does private health insurance cover external prostheses?

  Generally, private health insurance hospital cover primarily focuses on surgically implanted prostheses that are listed on the Australian government's Prostheses List. External prostheses, such as artificial limbs not surgically attached, may be covered under certain extras policies or through other government schemes like Medicare or the NDIS, depending on your circumstances. It is important to review your extras policy for specific benefits related to external medical appliances or ask your health fund directly.

• What if my prosthesis needs replacing or repairing?

  If a surgically implanted prosthesis needs replacing or repairing due to malfunction, wear and tear or a change in your medical condition, your private health insurance will typically cover the cost if the original implant was also covered under your policy and the replacement device is on the Prostheses List. Standard waiting periods may apply if the replacement is for a new condition or if you have recently upgraded your cover.

• Are dental prostheses covered by private health insurance?

  Dental prostheses, such as crowns bridges or dentures, are generally not covered under hospital policies. Instead, they are typically covered under extras health insurance policies that include major dental benefits. The level of cover for dental prostheses can vary significantly between different extras policies so it is important to check your policy's limits and exclusions.

• How do I make a claim for a prosthesis?

  To make a claim for a prosthesis, your doctor will generally submit the hospital admission and treatment details directly to your health fund and Medicare. Ensure your doctor uses a device from the Prostheses List for covered treatments. Any out-of-pocket expenses or gaps will be clearly outlined to you before your procedure. For external prostheses or specific consultations, you may need to submit an itemised receipt or doctor's letter to your health fund.

• Does health insurance cover consultations with a prosthetist?

  Consultations with a prosthetist for the assessment, fitting or adjustment of a prosthesis may be covered depending on your health insurance policy. If the consultation is part of a hospital admission for a surgically implanted device, it might be included in your hospital cover. For external prostheses, some extras policies may offer benefits for allied health services or medical appliances that could include prosthetist consultations.

• Can I get cover for a prosthesis if it relates to a pre-existing condition?

  Yes, you can get cover for a prosthesis related to a pre-existing condition but you will need to serve a 12 month waiting period before your health insurance benefits become active. A pre-existing condition is generally defined as an illness, ailment or condition that you had signs or symptoms of in the six months before taking out or upgrading your hospital cover, regardless of whether you or a doctor knew about it.

Written by

Gary Ross Hunter

Journalist

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Gary Ross Hunter has over 6 years of expertise writing about insurance, including life, health, home, and car insurance. Having reviewed hundreds of product disclosure statements and published over 800 articles, he loves simplifying complex insurance topics for everyday readers. Gary has contributed to major outlets like Yahoo Finance, The Sydney Morning Herald, and news.com.au, and holds a Bachelor of Arts (Honours) in English Literature from the University of Glasgow, along with a Tier 2 General Advice certification, ensuring his work adheres to ASIC’s RG146 standards. See full bio

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