Government prostheses arrangements
- Why did the government change the prostheses arrangements?
- What are the prostheses arrangements?
- When did the change become effective?
- What does the change mean?
- How much will I have to pay?
- Who receives the gap-prostheses payment?
- For further information download the New Prostheses Arrangements [PDF, 152k]
Why did the government change the prostheses arrangements?
The Commonwealth Department of Health and Ageing introduced changes to the prostheses arrangements in response to industry concerns about the spiralling cost of prostheses and the impact on the cost of private health care and health insurance. These arrangements are intended to ensure that health fund customers continue to have access to safe and clinically effective prostheses whilst maintaining the sustainability and affordability of private health insurance.
What are the prostheses arrangements?
Prostheses items have been evaluated by a group of doctors who are all specialists in their fields appointed by the Commonwealth Department of Health and Ageing. On the basis of available clinical evidence they have determined which ones are clinically comparable. Within each clinically comparable group, most devices are listed at no-gap, however there are other more expensive ones that will now attract a gap.
When did the change become effective?
The change came into effect on the 31st October 2005. Due to the large volume of items on the prostheses schedule that are being evaluated, the initial list has only a limited number of "gap" prostheses. These will be in the high volume areas of orthopaedics, cardiac and ophthalmology. The number of "gap" prostheses will grow as subsequent lists in other clinical groups are issued over time.
What does the change mean?
Under these arrangements, for every Medicare procedure there will be at least one prosthesis that will be no-gap. However in a small number of cases there will be other more expensive prostheses that your Specialist (Doctor) may recommend that will attract a gap. Ask your Specialist to explain the reasons why this one is being recommended for you.
How much will I have to pay?
Subject to waiting periods, any known Excess or Co-payment and any applicable exclusions on your level of cover, where your specialist recommends a gap prostheses for your surgery and you agree to that prostheses, you will have to pay a gap amount. The maximum gap amount is the difference between the minimum benefit amount for the no gap alternative prosthesis and the maximum benefit amount for the gap-permitted prothesis. If your Specialist recommends no-gap prosthesis this will be fully covered by your MBF hospital cover subject to the above conditions.
Ask your Specialist to explain the costs of your surgery including the prosthesis gap amount and any other expenses involved. If there are any gaps for you to pay ask for a written cost estimate. This written cost estimate is known as informed financial consent.
Obtaining this information is essential before any hospital admission. For more information on informed financial consent you can visit the Australian Medical Association's website.
If your Doctor has given you the code number for the prostheses MBF will be able to confirm the maximum gap amount.
Who receives the gap-prostheses payment?
When you are admitted to hospital for elective surgery the Specialist should have made the hospital aware that a gap-prosthesis will be used for your procedure. The hospital will ask you to the pay the prosthesis gap payment when you are admitted to hospital.
For further information download the New Prostheses Arrangements [PDF, 152k]
