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Prostheses

The Prostheses List (PL) is a schedule of medical devices and benefits that defines the minimum amount private health insurers are required to pay hospitals that utilise these devices in the provision of care to privately insured individuals. The PL forms part of the Private Health Insurance (Prostheses) Rules, which is a legislative instrument made under the Private Health Insurance Act 2007.

The PL uses billing codes to identify registered medical devices. There are 11,183 billing codes specified in the August 2022 publication of the PL, which are hierarchically categorised into parts, categories, subcategories, groups, subgroups and suffixes.

In 2021, the Australian Government Department of Health and Aged Care (the Department) commenced four years of reform activity to improve the PL and its arrangements. These reforms include changes aimed at improving the alignment of the PL scheduled benefits with prices paid in the public hospital system, streamlining the administration of the list, and better defining the purpose and scope of the PL. Revisions to the purpose and scope of the PL aim to provide greater clarity and certainty about which items are eligible for inclusion on the PL.

To support the implementation of the PL reforms, IHACPA has established a public benchmark price for prostheses in Australian public hospitals. This public benchmark price has informed benefit reductions implemented in the July 2022 publication of the PL.

To provide further support to the implementation of PL reforms, the Department has requested that IHACPA provide advice on bundling arrangements for General Use Items on the PL. The purpose of this advice is to support the private health sector in establishing alternative arrangements for the payment of benefits for these items once they are removed from the PL on 1 July 2023.

IHACPA will provide advice to the Department on alternative bundling arrangements for General Use Items on the PL in December 2022. If required, IHACPA will provide the Department with supplementary information in April 2023 to assist with the interpretation and use of its advice on alternative bundling arrangements.

Key link

Consultation Paper on Bundling Arrangements for General Use Items on the Prostheses List

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