Surgery - your choice of prosthesis
The Federal Government has made it easy to choose an effective surgically implanted prosthesis that won't leave you out-of-pocket.
What is a prosthesis?
A prosthesis is an artificial or substitute component such as a pacemaker, defibrillator, cardiac stent or joint replacement.
Before you have surgery, your surgeon will tell you if a prosthesis is required. For most surgical procedures, there is a choice of prostheses available. They can vary in cost and comparative benefits. Until now, there has been no simple way to compare the costs and benefits.
What are my choices?
The Government, together with a panel of doctors and other health specialists, has evaluated prostheses available in Australia and determined which ones are clinically comparable. The evidence shows that the most expensive prostheses are not necessarily the most appropriate ones.
As a result of this collaboration you and your surgeon are able to choose a prosthesis for every Medicare procedure which will be fully covered by your private health insurance. That means you will have no gap amount to pay.
Other more expensive prostheses may be available for your surgery but if you agree to have one of these, you will have to pay a gap amount. The gap amount is the difference between the prosthesis chosen by you and your surgeon and the ‘no gap’ alternative.
Examples of prosthesis choice:
- Bill is going to have a knee joint replacement operation.
Bill's surgeon has recommended a brand of prosthesis (Brand A) which is a no-gap prosthesis costing $3,000. Because it is a no-gap prosthesis, Defence Health will pay the full cost for the item.
- Sharon is going to have a knee joint replacement operation.
Sharon's surgeon has recommended an alternative brand of prosthesis (Brand B) which costs $200 more than the no-gap prosthesis. Defence will still pay the $3,000 towards the cost of the prosthesis. Sharon will be billed the balance of $200.
(The examples above are made up and assume no waiting periods apply.)
What do I need to do?
- Before you have any surgery, check with Defence Health that your private health insurance covers you.
- If your surgery requires a prosthesis, ask your surgeon which prosthesis will be the best one for you and which no-gap prostheses are available.
- If the surgeon recommends a prosthesis for which a gap is payable, ask why this one is being recommended. You will have to pay part of the prosthesis cost if you agree to have one of these devices.
- Ask the surgeon to explain the costs of the surgery including the prosthesis gap payment, if any, and any other expenses involved. If there are any gaps for you to pay, ask for a written cost estimate.
- Contact Defence Health again to confirm the amount of any gap payment.
Surgery - your choice of prosthesis
The Federal Government has made it easy to choose an effective surgically implanted prosthesis that won't leave you out-of-pocket.
What is a prosthesis?
A prosthesis is an artificial or substitute component such as a pacemaker, defibrillator, cardiac stent or joint replacement.
Before you have surgery, your surgeon will tell you if a prosthesis is required. For most surgical procedures, there is a choice of prostheses available. They can vary in cost and comparative benefits. Until now, there has been no simple way to compare the costs and benefits.
What are my choices?
The Government, together with a panel of doctors and other health specialists, has evaluated prostheses available in Australia and determined which ones are clinically comparable. The evidence shows that the most expensive prostheses are not necessarily the most appropriate ones.
As a result of this collaboration you and your surgeon are able to choose a prosthesis for every Medicare procedure which will be fully covered by your private health insurance. That means you will have no gap amount to pay.
Other more expensive prostheses may be available for your surgery but if you agree to have one of these, you will have to pay a gap amount. The gap amount is the difference between the prosthesis chosen by you and your surgeon and the ‘no gap’ alternative.
Examples of prosthesis choice:
- Bill is going to have a knee joint replacement operation.
Bill's surgeon has recommended a brand of prosthesis (Brand A) which is a no-gap prosthesis costing $3,000. Because it is a no-gap prosthesis, Defence Health will pay the full cost for the item.
- Sharon is going to have a knee joint replacement operation.
Sharon's surgeon has recommended an alternative brand of prosthesis (Brand B) which costs $200 more than the no-gap prosthesis. Defence will still pay the $3,000 towards the cost of the prosthesis. Sharon will be billed the balance of $200.
(The examples above are made up and assume no waiting periods apply.)
What do I need to do?
- Before you have any surgery, check with Defence Health that your private health insurance covers you.
- If your surgery requires a prosthesis, ask your surgeon which prosthesis will be the best one for you and which no-gap prostheses are available.
- If the surgeon recommends a prosthesis for which a gap is payable, ask why this one is being recommended. You will have to pay part of the prosthesis cost if you agree to have one of these devices.
- Ask the surgeon to explain the costs of the surgery including the prosthesis gap payment, if any, and any other expenses involved. If there are any gaps for you to pay, ask for a written cost estimate.
- Contact Defence Health again to confirm the amount of any gap payment.