Breast prosthesis subsidy

The breast prosthesis subsidy is payment to people who have:

• had a partial or full surgical breast removal (mastectomy), on one side or both
• had a lump removed (lumpectomy)
• congenital needs
• had reconstructive surgery, as specified by a specialist or GP.

You can claim for this subsidy if:

• you are a New Zealand citizen or are ordinarily resident in Aotearoa New Zealand
• your specialist or GP provides a current medical certificate with your National Health Index (NHI) number and confirms your need for breast prosthesis services.

Payments

Payment will be made within 20 business days of receiving a valid claim.

Your GP or medical specialist will talk to you about the breast prosthesis subsidy and provide a medical certificate. You then need to find a breast prosthesis supplier and choose the right product for you.

Once you have done this you can either:

• request the supplier make a claim to Health NZ (Sector Operations) for you
• make a claim yourself.

If the supplier makes the claim for you

The supplier will:

• fill in the details of the product and cost
• ask you to add your personal details and sign the form.

Where this is a first claim they will also need a copy of your medical certificate.

You do not pay for the product. But keep a copy of the receipt the supplier gives you for your records.

If you make the claim yourself

You pay for the product yourself. To claim a reimbursement you must first have a Health NZ (Sector Operations) payee number. For a payee number application form and a breast prosthesis claim form, contact Sector Operations.

Contact Sector Operations

You will need to complete the forms and return them to Sector Operations for reimbursement of your costs.

The breast prosthesis subsidy is available to cover the cost of the following items only:

• breast prostheses or breast forms — these may include standard breast forms, swim forms, foam filler, a shell prosthesis and lumpectomy shells
• special bras to hold the breast prostheses or breast forms
• surgical bras
• normal bras — the service includes 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.

If you buy an item that is more than your entitlement balance, you are responsible for the extra cost.

Your entitlement is $613.33 (GST inclusive) for each breast over a 4-year period. You may claim any amount up to $613.33 (or $1226.66 for both breasts) at any time during the 4-year entitlement period. The entitlement period begins on the date you make your first purchase from a supplier.

Roll over subsidies

If you have had surgery for breast cancer, a subsidy is set up which rolls over every 4 years. This applies if you have had a:

• lumpectomy, and you have significant breast asymmetry
• partial or full mastectomy without reconstruction
• partial or full mastectomy with incomplete reconstruction, where there is still a need for a breast prosthesis or prosthetic nipple.

Special circumstances

If you have had successful breast reconstructive surgery and your breasts are quite symmetrical, or there is no need for a prosthesis or prosthetic nipples, you can apply for an initial subsidy to purchase items such as post-operative bras. This subsidy does not roll over and ends after 4 years.

If your needs change later on,you can apply for a new subsidy. Submit another medical certificate with the details of any further procedure or change in needs.

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.

An initial subsidy can be applied for to purchase items such as post-operative bras. For this, the subsidy does not roll over but ends after 4 years.

The subsidy helps with the costs associated with regaining breast symmetry. It is not intended to cover all costs, or those resulting from normal wear and tear. You may need a new prosthesis and not have enough remaining credit in your subsidy entitlement to cover the costs.

In exceptional situations, Health NZ will consider:

• allowing access to your next entitlement earlier (early access)
• making the start date of your next entitlement earlier (new term)
• approving actual costs over and above your current entitlement (top up).

The criteria to request these exceptions are you:

• are under 18 and your general practitioner or specialist considers your development is incomplete, and your prosthesis or prostheses needs to be replaced regularly
• need a prosthesis or prostheses to regain symmetry following reconstructive surgery
• have had a significant change in need (due to a medical condition) meaning your current prosthesis is unsuitable, a difference in breast size and shape due to weight loss or gain, or deterioration of the prosthesis.

Issues with products purchased previously should be raised with the original supplier.

Where to send your claims

Send all completed forms to:

Breast Prosthesis Subsidy
Sector Operations
Private Bag 1942
Dunedin 9054

How to contact us

To order more forms, contact the Health NZ (Sector Operations) contact centre:

• email customerservice@health.govt.nz
• hone 0800 855 066 — option 3 for claims, subsidies and entitlements, then option 5 for artificial aids.

You will need to provide your payee number.

Our operating hours are:

• Monday, Tuesday, Thursday and Friday, 8am to 5pm
• Wednesday, 9:30am to 5pm.