Sector Services

Claims, Provider Payments & Entitlements

Breast Prosthesis Subsidy

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FAQs

What is the Breast Prosthesis Service Payment?
It is a 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 failed reconstructive surgery, as specified by a specialist or general practitioner (GP). The payments are to reduce the cost of purchasing Breast Prosthesis or prostheses and other related products. Sector Services, on behalf of the Ministry of Health, will pay this service payment to either the claimant or the supplier of the product.

Who can claim this service payment?
You may 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 details of your need for a Breast Prosthesis or prostheses.

How much can I claim?
Your entitlement is $600 (GST incl) per side for a four-year period. You may claim any amount up to the total amount of $600 (or $1200 for bilateral) at any time during the four-year entitlement period.

Note: The entitlement period begins on the date you make your first purchase from a supplier and ends four years from this date.

In addition to this:
You may apply to the Ministry of Health for an additional entitlement if your existing entitlement is insufficient because either:

you are under 18 and your GP or specialist considers that your growth is incomplete and your prosthesis or prostheses needs to be replaced regularly; or
you have lost a reconstructed breast due to infection after reconstructive surgery and need a replacement prosthesis or prostheses.

Requests for additional entitlement should be sent to:
Disability Services Directorate,
Ministry of Health,
PO Box 5013,
Wellington 6140.

What can I use the service payment 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 and normal bras
modifications to bras to hold a prosthesis or breast form
prosthetic nipples.

How do I claim?
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 Services 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 Services, 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 Services payee number. Ring Sector Services on 0800 458 448 for a Payee Number Application Form and a Breast Prosthesis Claim Form. You will need to complete the forms and return them to Sector Services for reimbursement of your costs.

Remember
Sector Services will not pay any claims unless they receive the following three items:

completed Breast Prosthesis Claim Form
proof of purchase (receipt) issued by the supplier
current Medical Certificate for initial claims.

When will my claims be paid?
Payment will be made within 20 business days of receiving a valid claim.

What if the product that I choose costs more than I am entitled to?
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 $95. You or the supplier can claim the other $600 from Sector Services.

What happens when my entitlement period ends?
At the end of your entitlement period any unspent amount will be cancelled and another four-year entitlement of $600 or $1200 will be credited.

Where do I send my claim?
Send all completed claims to:

Breast Prosthesis Subsidy
Sector Services
PO Box 1043
Wellington 6140

How do I contact Sector Services?
For further information, please call the Sector Services Contact Centre on:
0800 458 448
Monday – Friday 8:00am – 5:00pm,
Except Wednesday when the Contact Centre’s hours are 9:30am – 5:00pm

I have run out of claim forms, where can I get some more?
Claim forms are available free through Wickliffe Ltd on 0800 259 138, you will need to provide your payee number.

Links

Eligibility for Publicly Funded Health and Disability Services
Breast Prostheses Service Payments Notice (PDF, 110 KB)

Please note: you should not rely solely on the answers provided here; the contracts applicable to each provider and all relevant legislation must be consulted to determine the full rights & liabilities applicable to any service provider or funder

Page last updated: 5 August 2009