surgically implanted prostheses

A surgically implanted prosthesis is a piece of equipment that is surgically implanted into the body during a hospital procedure, to replace or assist a bodily function. For example, an artificial hip, a pacemaker, a cardiac stent, intraocular lenses, screws and plates.

Most Government approved surgically implanted prostheses are fully covered by your hospital cover. A limited number however, do require a patient contribution (gap) to be paid. The Department of Health and Ageing produces a list of approved prostheses showing which prostheses are to be fully covered by health funds and which prostheses may attract a patient gap.

Every procedure in the Medicare Benefits Schedule, that requires a prosthesis, will have at least one prosthesis available with no gap to pay. This means you and your surgeon will always have a choice to use a no gap listed prosthesis.

The Minister for the Department of Health and Ageing has appointed a committee, the Prostheses and Devices Committee (PDC), to oversee the listing and to make recommendations on what prosthetic items should be listed and what benefit levels should apply. The members of the PDC are appointed by the Minister and are drawn from private hospitals, clinicians, health funds, suppliers and consumers.

The PDC make recommendations based on advice received from Clinical Advisory Groups (CAG) who assess prostheses for clinical effectiveness. The Clinical Advisory Groups are made up of clinical specialists in the clinical area being examined.

Through benefit negotiators, the PDC determines a benefit for prostheses grouped into clinically equivalent categories that the CAG has advised have similar clinical effectiveness. Suppliers that agree to charge the negotiated benefit have their prosthetic item listed as a no gap item. Suppliers who do not agree with the negotiated benefit have their prothesis listed with a patient gap. Every procedure in the Medicare Benefits Schedule that requires a prosthesis has at least one prosthesis available with no gap. In fact the vast majority of prostheses listed have no gap.