Joint replacement health insurance
Health insurance can help cover the cost of replacing your hips, knees and other joints.
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Compare joint replacement health insurance
Below are some of the cheapest policies from Finder partners that cover joint replacement - most are silver plus policies, rather than gold policies. To compare health insurance from 30+ funds, click here.
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?
Joint replacements are partially covered by Medicare, but there will often be out-of-pocket costs in both the private and public system.
Medicare will pay for most 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 2019-2020, wait times were around 120 days for a hip replacement, and 223 days for a knee replacement.
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.
Is joint replacement covered by health insurance?
Joint replacement can be covered by private health insurance, but you will need to make sure that you get the right policy.
Hospital tier. Next, you'll need the right coverage level. Hospital cover comes in 4 tiers, and joint replacements are only mandatory with gold-tier policies. However, some lower tier policies (especially 'silver plus' policies) also have cover for joint replacements.
What costs will joint replacement health insurance cover?
While health insurance can cover the cost of joint replacements, the level of cover provided varies substantially between health funds and individual policies. Some insurers will completely exclude joint replacements from lower tier hospital policies, while others will only pay a restricted benefit or cover specific joints such as knees. If you require health insurance for joint replacements you will need to take out a high-level hospital policy, which will generally include benefits for:
- Accommodation in a public or private hospital
- Theatre fees
- In-hospital pharmaceuticals
- Doctor and specialist fees
- Physiotherapy fees to help with your recovery
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.
How much do Australians spend on joint replacement?
As Australia’s population continues to age, the incidence of arthritis and a range of other joint issues continues to increase. Unfortunately, this also means that a rising number of Australians require hip and knee replacements. To give you an idea of the costs involved, lets look at some figures:
Source of figures: https://www.privatehealthcareaustralia.org.au/variations-in-care-hip-and-knee-replacement/
Average national cost for knee and hip replacements from 2012 - 2013
Without private health insurance in place, joint replacement surgery can cost a substantial amount of money, as can be seen below.
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, so the procedure has some of Australia's longest surgery waiting times. In 2019-2020, the wait time for a total hip replacement was around 120 days, and the wait time for a total knee replacement was 223 days. Going private can help you get surgery much sooner than this.
Frequently asked questions
- Finder: How long are public hospital waiting times?
- AIHW: More patients, longer waiting times for both elective surgery and emergency department care
- Sydney Morning Herald: Same surgery different surgeon: Huge variations in out-of-pocket costs for orthopaedic operations
- PrivateHealth.gov.au: Joint replacements - MBS items
- Services Australia: Health care and Medicare
- MBS Online: Changes to MBS items for orthopaedic surgery services
- Advanced Bone and Joint: Joint Reconstruction vs. Joint Replacement
- Harvard Health Publishing: Joint Replacement
- Data source: Private Health Insurance Ombudsman
- Icons made by Freepik from flaticon.com
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