EXPLANATORY STATEMENT
Issued by Authority of the Minister for Health and Ageing
National Health Act 1953
Determination under subsections 73AAG (6) and (7)
(HIB13/2005)
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 Tissues.
The Schedule to this determination is known as the “Prostheses List”.
This determination commences on 31 October 2005. Schedule 5 (Benefits Payable in Respect of Prostheses and Human Tissues) will be removed from the determination made under Schedule 1, paragraph (bj) of the Act on 24 June 2005 (as amended) with effect on 31 October 2005.
The Department of Health and Ageing will receive applications from suppliers and/or manufacturers of prostheses and human tissues to include products on the Prostheses List in February and August of each year. The Prostheses List is then amended as necessary.
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.
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 available.
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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 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 members from the major stakeholder groups – the Australian Health Insurance Association, the Australian Private Hospitals Association, Catholic Health Australia, the Australian Medical Association, the Consumers’ Health Forum, the Medical Industry Association of Australia, and the Commonwealth Department of Veterans’ Affairs. The PDC considered applications for listing of new products, applications for changes to products already listed in Schedule 5, and the benefits payable for all products, and made recommendations. In making their recommendations, the PDC were advised by CAGs, other clinical experts, and benefits negotiators, all appointed by the PDC.
The time between the making of the determination and its commencement on 31 October 2005 is to enable health funds and hospitals to establish new systems to support the new arrangements. It is also to allow time for patients to be appropriately informed by doctors, hospitals and health funds of the health fund benefit they can expect for their prostheses, on and after 31 October 2005.
The Determination and this explanatory statement have been lodged for registration on the Federal Register of Legislative Instruments.
PRIVATE HEALTH INSURANCE BRANCH
DEPARTMENT OF HEALTH AND AGEING
AUGUST 2005