Health Insurance Coverage for Prostheses & Joint Replacement

Published: October 25, 2018

People have all sorts of artificial devices implanted to improve their quality of life. Your grandpa might need a hip replacement someday, your spouse could require a pacemaker to rectify an irregular heartbeat, or you might need a knee replacement after a severe sports injury.

Prostheses cost thousands of dollars but can generally be wholly or partly covered by Medicare and private health insurers. Under the Private Health Insurance Act (2007), private health funds must pay benefits to prostheses that are included in the Prostheses List when received as part of your hospital treatment or hospital substitute treatment when a Medicare benefit is payable for the service.

According to The Department of Health, 14% of private hospital insurance is paid to prostheses. Find out if your private health insurance policy covers you for prosthetics like joint replacements, cochlear implants, and heart valve replacement.

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What is the Prostheses List?

The Australian Government prostheses list contains over 10,000 prostheses and includes the Protheses Rules which help to ensure the benefits shown on the Prostheses List is the amount you’re reimbursed for by your private health fund. The List is divided into categories. Within each category, products are grouped to similar clinical effectiveness, and each grouping has a single group benefit.

Will Medicare pay for prostheses?

Medicare covers 75% of the prosthetics listed in the Medicare Benefit Schedule (MBS). Generally, Medicare will pay for the products listed on the Prostheses List and the benefit amount payable is in respect to the professional services associated with the delivery of the product. Go to MBS Online to find the item you're interested in, and the cost breakdown will be shown.

Does health insurance cover prosthetics?

Generally, if you have private health insurance and the prostheses are implanted in a public hospital, then your health fund must pay the group benefit OR your liability to the hospital for the prosthesis, whichever is the lesser amount. Your private health insurance must generally pay the minimum benefit listed on the Prostheses List.

Generally, private health insurers must pay prostheses benefits when:

  • You have the appropriate level of health cover,
  • Cover is provided as part of hospital treatment or substitute treatments, and
  • There is a Medicare benefit payable to the service.

Gap vs no-gap prostheses

You might have to pay an additional cost when the minimum benefit does not cover the value of the prostheses to the hospital. The gap is the difference between the minim benefit payable and the cost of your prosthetics.

No-gap prostheses

Your private health insurer is generally required to cover the cost of at least one prosthesis for medical procedures covered by the MBS.

Gap prostheses

When an alternative prosthesis is issued that costs more than the ‘no-gap' version, you'll usually have to pay the difference between the ‘no-gap' amount and the total fee charged by the supplier.

Before you book your surgery, it's crucial that you check with your insurer if you’re covered for prostheses, how much they’ll cover, and whether you’ll have to pay any ‘gap’ surgery.

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The 13 categories on the Prostheses List

  1. Cardiac
  2. Cardiothoracic
  3. Hip
  4. Knee
  5. Ophthalmic
  6. Specialist orthopaedic
  7. Spinal
  8. Urogenital
  9. Vascular
  10. Ear, nose and throat
  11. Neurosurgical
  12. Plastic and reconstructive
  13. General miscellaneous: Products not included in other categories.

What’s not covered by the Prostheses List?

  • External devices, like hearing aids and prosthetic limbs,
  • External breast prostheses, and
  • Implants solely for cosmetic reasons.

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Private health insurance prostheses reforms

In February 2018, the minimum benefit payable to medical devices listed on the Prostheses List were reduced. Private health funds save money on reduced expenditure on the prosthesis, which they then pass on to their customers in the form of reduced premiums.

Definition of prostheses as it pertains to health insurance

According to the Australian Government Department of Health, the type of prostheses included in the Prostheses List are those devices that are:

1 Surgically implanted and designed to

  • Replace an anatomical body part, for example, hip and knee replacements.
  • Combat a pathological process, meaning repair or correct a pathological process, for example, cardiac and vascular stents.
  • Modulate a physiological process, in other words, to block or facilitate a process, for example, pacemakers to regulate your heartbeat.

OR

2 Essential and specifically designed to enable the implantation of the above product

These products are ‘only for use once’ during your treatment. If capable of reuse or repurpose it will not be covered. For example, a preloaded coronary stent with a balloon catheter that can only be used once to implant a stent.

OR

3 Critically important to the ongoing function of the surgically implanted product

Associated products that have an ongoing role and are critical to the function of the implanted prosthesis, meaning it remains with you as part of the prosthesis. For example, a cochlear speech processor.

How to check if you're covered for prostheses

  • Make sure your policy clearly states that you are covered for the type of prostheses you expect you'll need. For example, does your hospital policy cover hip replacement surgery. Check that it's not excluded in your policy terms and conditions.
  • If your procedure requires protheses, ask the surgeon which one they recommend.
  • Inquire if no-gap prostheses are available and if it would be a good option.
  • Request that your surgeon explains the costs, and possible out-of-pocket expenses, to you in detail. For example, fees pertaining to the surgery, hospital stay and prosthetic.
  • Contact your private health insurance provider before your surgery and confirm that you're covered.
  • Inquire whether the surgery and prostheses are fully covered or whether there will be a gap payment.

Frequently asked questions and answers

How long do I have to wait to receive a prostheses benefit?

After joining private health insurance, the waiting period for joint replacements and prostheses is generally 12 months. This is because it is usually viewed as a pre-existing condition, meaning an ailment, illness, or condition where a medical adviser is of the opinion that the signs or symptoms existed at any time 6 months before you purchased or upgraded your policy.

How much does a hip replacement cost without insurance?

Hip replacement costs will vary depending on the fees of your surgeon, anaesthetist and the hospital. Without private health insurance, the procedure can be costly. According to the Medicare Benefit Schedule, item number 49318 can cost about $1,317.80 with Medicare covering 75%, $988.35. Meaning, without insurance a hip replacement can result in an out-of-pocket cost of $329.45.

How much does it cost to get a cochlear implant?

Medicare will generally cover 75% of the cost for a cochlear implant, including the insertion of the device and the mastoidectomy. The average cost for item 41617, under the subgroup of ear, nose and throat, is $1,895.20. Medicare usually pays $1,421.40, so without private hospital cover, you'll be responsible for paying the remaining $473.80.

What’s the average cost of knee replacement in Australia?

Under the Therapeutic Procedure category of the Prostheses List, knee replacement falls under the subgroup Orthopaedic. For one total knee replacement without bone grafting or removal of the prosthesis, the average cost runs to $1,317.80 with Medicare usually paying $988.35 of the price. Without insurance, your out-of-pocket cost could be about $329.45.

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