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What you need to know
Joint replacements are covered under all gold hospital policies, as well as some silver plus policies.
Cover for joint replacements starts from around $38 a week.
We update our data regularly, but information can change between updates. Confirm details with the provider you're interested in before making a decision.
All prices are based on a single individual with less than $90,000 income and living in Sydney.
Is joint replacement covered by Medicare?
Public system
Medicare will pay for all of the cost of a joint reconstruction in a public hospital. There should be minimal out-of-pocket costs to pay, although there may be some, depending on your circumstances. The main downside of using the public system is that you'll have longer surgery wait times. In 2021-22, wait times were around 153 days for a hip replacement, and 293 days for a knee replacement.
Private system
In the private system, Medicare will pay some of the cost, but you'll need to cover the rest. Specifically, the Medicare Benefits Schedule (MBS) lists benefits for a wide range of joint replacements, but Medicare only covers 75% of the listed fee. That means you'll need to pay the remaining amount out-of-pocket or by using private health insurance.
Your private health insurer will also cover the cost of the surgically-implanted prosthesis used to replace your joint. The Australian Government's Prostheses List outlines all the prostheses for which private health insurers must pay a benefit.
Out-of-pocket costs for joint replacements
Even with private health insurance, there will probably be an additional cost (or gap) that you will have to pay. The amount covered by health funds varies significantly, as does the amounts charged by surgeons. This can affect the out-of-pocket costs that you have to pay on top of your private health insurance, with the differences sometimes in the thousands of dollars. Make sure you speak to your health fund, GP and any prospective surgeon about the final cost of the surgery.
Waiting periods for joint replacements
There are two types of 'waiting period' that are relevant to joint replacements, but the terms are similar. There's the health insurance waiting period then there are the public hospital surgery waiting times.
Health insurance waiting period
When you get private health insurance that covers joint replacements, there is a 2-month waiting period before you can make a claim. If you have a pre-existing condition (including arthritis) then you'll need to wait for 12-months before you can claim.
Public hospital surgery waiting times
If you decide to use Medicare and get a joint replacement in the public system, then you'll have to wait for you surgery to be scheduled. Unfortunately, there are lots of public patients that need joint replacements, and waiting times have increased significantly since the COVID-19 pandemic. In 2021-22, the wait time for a total hip replacement was around 153 days, and the wait time for a total knee replacement was 293 days. Going private can help you get surgery much sooner than this.
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Frequently asked questions
Joint replacement is covered by gold-tier hospital policies but it is also included on many 'silver plus' policies, which cover treatment categories on top of those that are required for its coverage tier.
In the public system, Medicare will cover most or all of the costs associated with a joint reconstruction, so out-of-pocket costs should be small. In the private healthcare system, Medicare will still pay 75% of the MBS fee associated with your surgery, but you'll have to account for the rest with private health insurance or paying for it yourself.
Joint replacement is major surgery that involves replacing an entire joint with prosthetic materials, whereas joint reconstruction aims to rebuild some of the joint architecture, which sometimes also involves some prosthetic parts. Reconstructions are normally faster and require less recovery time. In Australia, joint replacement requires gold hospital insurance to be covered in the private system. Joint reconstruction is covered by bronze hospital cover.
Yes, arthritis is considered a pre-existing condition for private health cover and will affect your waiting periods for joint replacement health insurance. Generally, this will add a 12 month waiting period.
Arthritis is the main contributing factor when Australians require joint replacement surgery. This debilitating condition affects more than 3.8 million Australians, and Arthritis Australia predicts that some 7 million people will suffer from arthritis by 2050.
While arthritis is commonly seen as a problem that only affects the elderly, almost 2.4 million Australians who currently suffer from arthritis are of working age. With this in mind, it's worth re-assessing your health insurance needs as you grow older and considering whether you might be able to benefit from a policy that provides comprehensive cover for joint replacements.
Tim Bennett is a Finder insurance expert. For over 10 years he's reported on news, politics, finance and other topics as a journalist and radio presenter. Tim's roles have included radio news reader and breakfast at the ABC, news producer for SBS and producer for Fairfax Media. Tim regularly appears as a health insurance expert on programs like Sunrise and SBS news, as well as in the Australian, The Daily Telegraph, The Courier Mail and more.
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