Fact Sheet

Surgically Implanted Prostheses

In October 2005, the Federal Government implemented changes to the way surgically implanted prostheses are funded in Australia.

In a minority of cases the changes may result in some prostheses requiring a patient gap to be paid. The Gap is the cost between the No Gap price for a clinically equivalent device and the price that the supplier has set.

It is a piece of equipment that is surgically implanted into the body during a hospital procedure, to replace or assist a body part or function.  Examples of prostheses include pacemakers, defibrillators, cardiac stents, joint replacements and intraocular lenses.

• NO GAP and GAP prostheses items have undergone a rigorous evaluation process to ensure that all items in a listed group are clinically equivalent and that items listed as GAP items do not provide any better clinical outcomes to those NO GAP items in the same group.
• National setting of prosthesis prices across the health industry
• Listed Prosthesis devices are for the first time subjected to a clinical review
• Clinical review is attended by specialists in the clinical fields of practice
• Prosthesis devices that are evaluated to be clinically equivalent are grouped together and one negotiated benefit determined to cover all these grouped devices. This then becomes the NO GAP Benefit
• Suppliers that agree to charge the negotiated benefit will have their prosthetic device listed as a NO GAP item
• Suppliers of a clinically equivalent prosthesis device who do not agree to charge the negotiated benefit will have their prosthetic device listed as a GAP item
• The difference between the NO GAP benefit and the GAP price will be charged to the patient
• Every procedure in the Medicare Benefits schedule that requires a prosthesis will have at least one prosthesis available with no gap that is clinically equivalent to the GAP item. 
• In fact the vast majority of prosthesis will have no gap.

• Previously there was no formal independent clinical evaluation relating to the listing of prostheses.
• Allows benefits to be paid relative to the clinical effectiveness of the prostheses
• 25% increase per annum on prostheses expenditure over the last 3 years
• Access to safe and clinically effective prostheses whilst maintaining the sustainability of private health insurance

• Members ability to have access to high quality clinically equivalent prostheses with a NO GAP benefit that provides no different clinical outcomes to that of a GAP prosthesis item
• The clinical evaluation process has assured that a Doctors/members choice is not limited

• Check with your surgeon whether the planned prosthesis is a NO GAP or GAP permitted item.
• If a GAP permitted item discuss with your surgeon the option of using a NO GAP listed prosthesis
• In cases of a GAP permitted item your surgeon should obtain your informed financial consent and advise you prior to surgery of the amount of gap you will be required to pay.
• Contact Latrobe Health Services prior to surgery to confirm your benefit entitlements