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Back to basics – the Prostheses List and Private Health Insurance

Despite the significant value that it adds to your private health insurance, if you’re one of the more than 3.5 million Australians who has insurance, chances are you might not know the answer to this question.

So, what is the Prostheses List?

Put simply, the Prostheses List is a list of medical devices for which insurers are required to pay a benefit when a member has the relevant coverage.

For example, if you had hospital orthopaedic cover and you needed a hip replacement, your health fund would be required to pay the minimum benefit for any artificial hip on the Prostheses List.

The Prostheses List is a crucial contributor to the value of private health insurance, enabling members to receive the best quality health care as determined by their doctor.

The Prostheses List ensures that surgeons can choose the best available prostheses for privately insured patients without the options being restricted by health funds.

There are approximately 11,000 items on the Prostheses List. The List is divided into Parts A, B and C.

Part A covers devices that are used as part of hospital or hospital substitute treatment where a Medicare benefit must be paid to the doctor for the procedure performed. The device must be surgically implanted in the body or enable another device to be implanted or allow an implant to continue to function after surgery.

Devices on Part A also must be approved for use by the Therapeutic Goods Administration and assessed for effectiveness and cost against other products by the Prostheses List Advisory Committee before they can be listed.

Part A is divided into 13 major categories according to the broad conditions they address, and is further divided into sub-categories, groups and sub-groups. Each prosthesis has its own billing code with a benefit that must be paid for the device.

Part B covers products that are derived from human tissue for treatment of a condition. Part C covers specific groups of medical devices which don’t meet the criteria of Part A but which the Minister for Health considers suitable for benefit payments by private health insurers.

Contrary to popular belief, external prostheses, such as artificial limbs, or prostheses used for cosmetic rather than reconstructive purposes, are not eligible for reimbursement according to Prostheses List criteria.

Despite the cost of private health insurance being a top level concern for many Australians, the existence of the Prostheses List and the major contribution that it makes to the value of private health insurance is largely unknown.

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