9Benefits for prostheses provided as part of hospital treatment

9 Benefits for prostheses provided as part of hospital treatment

(1) For a no gap prosthesis (other than a no gap prosthesis referred to in subrule (1A)) provided as part of an episode of hospital treatment in a private hospital, the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in Schedule 1 under the heading ‘Minimum Benefit’. (1A) For:

a no gap cardiac ablation catheter, mapping catheter for catheter cardiac ablation, or patch for cardiac ablation, provided as part of an episode of hospital treatment in a private hospital and used in a surgical procedure described in Medicare Benefit item 38287 or 38290 and where the procedure is for the treatment of atrial fibrillation; or

a no gap monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation or probe for surgical cardiac ablation provided as part of an episode of hospital treatment in a private hospital and used in a surgical procedure described in Medicare Benefit item 38512 or 38515.

the minimum benefit and the maximum benefit for the prosthesis are as follows:

if the sum of the default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the minimum benefit and the maximum benefit are each the default minimum benefit for the prosthesis;
if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the minimum benefit and the maximum benefit are each to be calculated using the following method: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.

Note: For example, if a cardiac ablation catheter, a mapping catheter for cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the minimum benefit and maximum benefit for the cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399.

(2) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a private hospital: (a) the minimum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Minimum Benefit’; and (b) the maximum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Maximum Benefit’. (3) For a no gap prosthesis (other than a no gap prosthesis referred to in subrule (3A)) provided as part of an episode of hospital treatment in a public hospital: (a) the minimum benefit is the lesser of the following amounts: (i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in Schedule 1; or (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and (b) the maximum benefit is the amount for that prosthesis listed in the column under the heading 'Minimum Benefit' in Schedule 1. (3A) For a no gap cardiac ablation catheter, mapping catheter for catheter cardiac ablation or patch for cardiac ablation, provided as part of an episode of hospital treatment in a public hospital and used in a surgical procedure described in Medicare Benefit item 38290 or 38287 and where the procedure is for the treatment of atrial fibrillation, or a no gap monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation system for surgical cardiac ablation or probe for cardiac ablation, provided as part of an episode of hospital treatment in a public hospital and used in a surgical procedure described in Medicare Benefit item 38512 or 38515: (a) the minimum benefit for the prosthesis is the lesser of: (i) the amount for that prosthesis calculated in accordance with subrule (3B); or (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and (b) the maximum benefit is the amount for the prosthesis calculated in accordance with subrule (3B). (3B) The amount for a prosthesis calculated in accordance with this subrule is the following amount: (a) if the sum of default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the amount is the default minimum benefit for the prosthesis; (b) if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the amount is to be calculated as follows: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.