About the Breast Prosthesis Subsidy
Note: You should not rely solely on the answers provided here. The full rights and liabilities applicable to any service provider or funder must consult the contracts applicable to each provider and all relevant legislation.
Who it's for
The Breast Prosthesis Service Payment is payment to people who have undergone a partial or full mastectomy, either unilateral or bilateral, and/or have undergone a lumpectomy, have congenital needs, or have had reconstructive surgery, as specified by a specialist or general practitioner (GP).
Who can claim
You can claim for this service payment if you:
- are a New Zealand citizen, or are ordinarily resident in New Zealand; and
- your specialist or GP gives you a current medical certificate with your NHI number, and confirms your need for breast prosthesis services.
Payment will be made within 20 business days of receiving a valid claim.
How to make a Breast Prosthesis Subsidy claim
Sector Operations will not pay any claims unless they receive the following 3 items:
- completed Breast Prostheses Claim Form
- proof of purchase (receipt) issued by the supplier
- current Medical Certificate for initial claims.
Your GP or specialist will inform you about the service payment and issue you with a medical certificate for your claim. All you will then need to do is go to a breast prosthesis supplier and choose the right product for you. Once you have chosen your product you may either request the supplier to make a claim to Sector Operations on your behalf, or make a claim yourself.
Claim by supplier
The supplier will fill in details of the product and its cost on the Breast Prosthesis Claim Form, and then ask you to fill in your personal details and sign the form. The supplier will then complete an additional form (stating that they are claiming on your behalf) and forward both forms to Sector Operations, with your medical certificate (where this is your first claim). You do not pay for the product yourself but keep a copy of the receipt the supplier gives you for your records.
Claim by you
You pay for the product yourself. To make a claim for reimbursement you must first have a Sector Operations payee number. Ring Sector Operations on 0800 855 066 – option 2 for a Payee Number Application Form and a Breast Prosthesis Claim Form. You will need to complete the forms and return them to Sector Operations for reimbursement of your costs.
What you can use the subsidy for
The service payment is available to cover the cost of the following items only:
- breast prosthesis or breast forms (these may include standard breast forms, swim form, foam filler, shell prosthesis and lumpectomy shells)
- special bras to hold the breast prosthesis or breast forms
- surgical bras
- normal bras (the services include the modification of a normal bra to hold breast prostheses or breast forms, or modifications to alternative undergarments where a person cannot wear a bra due to their medical condition)
- modified swimwear to hold a swim form
- prosthetic nipples.
Note: Where an item is purchased that is more than your entitlement balance you are responsible for the additional cost. For example, if for your first purchase you choose a product that costs $695, the final cost to you will be $81.67. You or the supplier can claim the other $613.33 from Sector Operations.
How much you can claim
The entitlement period begins on the date you make your first purchase from a supplier and ends 4 years from this date.
Your entitlement is $613.33 (GST incl) per side for a 4-year period. You may claim any amount up to the total amount of $613.33 (or $1226.66 for bilateral) at any time during the 4-year entitlement period.
Roll over subsidies
When a client has undergone surgery for breast cancer, i.e., a lumpectomy, partial mastectomy or full mastectomy without reconstruction or with incomplete reconstruction and where there is still a need for breast prosthesis or prosthetic nipples, a subsidy is set up that rolls over every four years.
When a client has had successful reconstructive surgery and there is no significant asymmetry or need for prosthesis or prosthetic nipples, an initial subsidy can be applied for to purchase post-operative bras etc.
In this instance, the subsidy does not roll over but ends after four years. If the client's needs change at a future date, a new subsidy can be applied for by submitting another medical certificate confirming the details of any further procedure or change in needs.
What happens when your entitlement period ends
At the end of your entitlement period any unspent amount will be cancelled and another 4-year entitlement of $613.33 or $1226.66 will be credited.
Note: an initial subsidy can be applied for to purchase post-operative bras etc. In this instance the subsidy does not roll over but ends after four years.
Exceptions to the Policy – Breast Prostheses Subsidy
The Breast Prosthesis Subsidy contributes to the costs associated with regaining breast symmetry, but it is not intended to cover all costs, such as normal wear and tear.
You may need a new prosthesis and you do not have adequate funds in your Breast Prosthesis Subsidy entitlement to cover these costs.
In exceptional situations, Te Whatu Ora will consider:
- allowing access to your next entitlement earlier (Early Access)
- making the start date of your next entitlement earlier (New Term), or
- approving actual costs over and above your current entitlement (Top Up).
The criteria to request these are:
- You are under 18 and your registered General Practitioner or Specialist considers that your development is incomplete, and your prosthesis or prostheses needs to be replaced regularly.
- You need a prosthesis or prostheses to regain symmetry following reconstructive surgery.
- You have had a significant change in need (due to a medical condition) resulting in your current prosthesis being unsuitable, a difference in breast size and shape due to weight loss or gain or deterioration of the prosthesis.
Note: Issues with products purchased previously should be raised with the original supplier.
Where to send your claims
Send all completed claims to:
Breast Prosthesis Subsidy
Private Bag 1942
How to get more claim forms
Call us on 0800 855 066 to order more forms. They're free, but you'll need to provide your payee number.