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 around 11,000 billing codes listed on 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 released its Consultation Paper on Bundling Arrangements for General Use Items on the Prostheses List for public consultation from 14 September to 12 October 2022. A total of 20 submissions were received to the consultation. All submissions have been published on IHACPA's website unless respondents specifically identified sections to be kept confidential for commercial or other reasons.
In December 2022, IHACPA provided the Department with Advice on Bundling Arrangements for General Use Items on the Prostheses List.
In April 2023, IHACPA provided the Department with Supplementary advice on Bundling Arrangements for General Use Items on the Prostheses List to assist with the interpretation and use of its December 2022 advice on alternative bundling arrangements.