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Te Whatu Ora Entitlements

Te Whatu Ora Entitlements

The Breast Prosthesis Service Payment is funding available 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, AND as a result of these procedures require a breast prosthesis or change of prosthesis, as specified by a specialist or general practitioner (GP).

What is the purpose of the breast prosthesis service payment?

The primary purpose of the funding is to assist those who need to purchase a breast prosthesis. However, you may be eligible for a one-off funding allowance that is not renewable every four years, if you require specialty bras following one of the above procedures, but do not need a breast prosthesis.

The payments are to reduce the cost of purchasing a breast prosthesis or prostheses and other related products. This is usually paid directly to the supplier of the product, who will be registered with Te Whatu Ora - Health New Zealand. However, you can also claim the funding yourself directly if you apply for a claimant code.

Funding is now available if you have significant asymmetry (a significant difference in size between your breasts) and need a breast prosthesis for symmetry, whether that occurs as a result of surgery, or naturally. That includes if you still have asymmetry after a reconstruction.

At The Fitting Room, we have a template letter we can give you to take to your GP or specialist, outlining for them what details are needed for the medical certificate, covering any of the above situations.

Who can claim this service payment?

You may claim 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 breast prosthesis services.

How much can I claim?

Your entitlement is $613.33 (GST included) 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. The entitlement period begins on the date you make your first purchase from a supplier and ends 4 years from this date.

What if the products I choose cost more than I am entitled to?

Where items are purchased that are more than your entitlement balance, you are responsible for the additional cost. For example, if for your first purchase totals $695, the final cost to you above the $613.33 (that will be claimed), will be $81.67.

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

  • 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)

  • Swimwear with a built-in modification to hold a swim 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. At The Fitting Room, we have a template letter we can give you to take to your GP or specialist, outlining what details are needed for the medical certificate. Generally, they are aware of what needs to be provided to you.

Stores that stock breast forms and pocketed bras are registered with Te Whatu Ora and can make the claim on your behalf. You need to take the doctor's letter/certificate with you to the shop for your first claim.

We recommend making an appointment with us at The Fitting Room so that one of our trained and experienced fitters will be available when you arrive and a changing room will be set aside. We will help you find and choose the right products for you.

We then process the claim on your behalf; all you will need to do is sign a form. You do not pay for the product yourself, but keep a copy of the receipt for your own records. If your medical certificate has all the necessary details or we have confirmed your funding balance, you can take the products away on the day.

If you wish, you can pay for items yourself and claim the subsidy back. However, it is a more complicated process. See here.

What happens when my entitlement period ends?

At the end of your entitlement period, any remaining amount will be cancelled and another 4-year entitlement of $613.33 or $1226.66 will be allocated. You can phone Te Whatu Ora yourself on 0800 458 448 to find out how much subsidy you have left. The Fitting Room or another registered retailer can also phone on your behalf if they have your permission alongside your date of birth and other details.

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.

The above information has been sourced and adapted from here.

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