Background – The goal of this fact sheet is to explain to someone not familiar with it what the PL is and why it should be valued/retained]
Key points
- Health insurers must pay a benefit for devices on the Prostheses List
- The Prostheses List ensures fund members can access the prostheses chosen by their doctor
- The Prostheses List expenditure is only 8% of insurer total revenue and falling over time
The Prostheses List (PL) is a list of medical devices for which insurers are required to pay a benefit when a member has the relevant coverage. This requirement is set out in the Private Health Insurance Act 2007.
For instance, if a member of a health fund has hospital orthopaedic cover and requires a hip replacement, their health fund would be required to pay the minimum benefit for any artificial hip on the PL.
The PL ensures that surgeons can choose the best available prostheses for privately insured patients without the options being restricted by health funds.
The PL is an essential part of the private health insurance offering, enabling members to receive the best quality health care as determined by their doctor with no out of pocket costs for the medical device.
Demand for prostheses has been growing due to population ageing, chronic health conditions and the introduction of new technology. However, expenditure on the PL is only 8% of total insurer revenue and is only 3% higher than 5 years ago while volume grew by 18% in the same period.
All devices must be used as part of hospital or hospital substitute treatment where a Medicare benefit must be paid to the doctor for the procedure performed. They 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.
Items on the PL are divided into Parts A, B and C. Part A covers devices that are surgically implanted in the body or enable another device to be implanted or allow an implant to continue to function after surgery.
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 implantable 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 on the Prostheses List.
The Prostheses List is now updated 3 times a year on 1 March, 1 July and 1 November. It is published as the Private Health Insurance (Prostheses) Rules and notification of the list is provided through Private Health Insurance Circulars issued by the Department of Health.
APRA Private Health Insurance Statistics September 2022
The Prostheses List is now updated 3 times a year on 1 March, 1 July and 1 November. It is published as the Private Health Insurance (Prostheses) Rules and notification of the list is provided through Private Health Insurance Circulars issued by the Department of Health.
