EXPLANATORY STATEMENT
Issued by Authority of the Minister for Health and Ageing
National Health Act 1953
Determination under subsections 73AAG (6) and (7)
(HIB 05/2006)
Subsection 73AAG(6) of the National Health Act 1953 (the Act) provides that the Minister may determine in writing the prostheses that are no gap prostheses and the benefit amount for each no gap prosthesis.
Subsection 73AAG(7) provides that the Minister may determine in writing the prostheses that are gap permitted prostheses, and the minimum and maximum benefit amounts for each gap permitted prosthesis.
The Schedule to this determination has two parts:
- Part A – Prostheses; and
- Part B – Human Tissue List.
The Schedule to this determination is known as the “Prostheses List”.
This determination commences on 14 March 2006. It replaces, in its entirety, the determination dated 19 October 2005 (HIB18/2005), as amended (by HIB23/2005).
This determination updates the previous Prostheses List by:
- adding a number of new products as no gap prostheses or gap permitted prostheses;
- changing some existing products including: amending the descriptions of products, allocating new billing codes in respect of new sizes or models of products, compressing billing codes to cover a range of products offered at the same cost, changing supplier names to reflect new supplier arrangements, changing the minimum benefit amount and/or maximum benefit amount; and
- deleting other products.
The determination is consistent with the recommendations of the Prostheses and Devices Committee.
In Part A of the Prostheses List, some products are grouped according to their clinical effectiveness, as assessed by Clinical Advisory Groups (CAGs). The purpose of the groupings is to identify products of similar clinical effectiveness or clinical design, in order to assist in determining the benefits payable for the products and to assist with clinical choice. To date, CAGs have assessed and grouped products for the Prostheses List in the following categories:
- cardiac pacemakers and leads;
- implantable cardioverter defibrillators and leads;
- cardiac stents;
- intraocular lenses;
- hip prostheses; and
- knee prostheses.
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Other products have been grouped according to their product type, as determined by the Emergency Care Research Institute (ECRI) or Global Medical Devices Nomenclature System (GMDNS) descriptor allocated by the Therapeutic Goods Administration. This is to allow for greater ease of comparison of products listed.
Benefits payable in respect of the products that have been assessed and grouped by CAGs, and new products, have been negotiated with the suppliers. Benefits payable in respect of products that have not yet been assessed and grouped by CAGs have been determined by application of a formula taking into account the benefits payable in respect of each product as at 1 October 2004 and, where available, the utilisation of each product.
CONSULTATION
This Determination has been made having regard to advice provided by the Prostheses and Devices Committee (PDC), a ministerially appointed committee comprised of nominees from health funds, hospitals, clinicians, prostheses and devices suppliers, the Commonwealth, and consumer representatives. In making their recommendations, the PDC were advised by CAGs, other clinical experts, and benefits negotiators, all appointed by the PDC.
This determination and this Explanatory Statement have been registered on the Federal Register of Legislative Instruments.
PRIVATE HEALTH INSURANCE BRANCH
DEPARTMENT OF HEALTH AND AGEING
FEBRUARY 2006