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Health insurance for hip replacement surgery
This guide explains what Medicare and private health insurance will cover with hip replacements.
If your doctor has recommended you get a hip replacement, it's worth considering the options Medicare and private health insurance provide to see how they can help reduce the cost of treatment.
When might you need hip replacement surgery?
Hip replacement is usually recommended after other treatments like physical therapy, exercise and medication have failed to improve your condition. You may need a hip replacement if:
- Your pain isn't improved by medication
- Your hip has become weak and unstable
- Pain stops or limits you from getting out and being as active as normal
- Pain affects your sleep
How does Medicare cover hip replacement surgery?
Medicare covers most medically necessary surgeries like hip replacements. Public patients should have no out-of-pocket expenses for surgery in a public hospital. Additionally, Medicare pays 75% of the Medicare Benefits Schedule (MBS) to private patients in public hospitals, meaning it will cover 75% of the public rate for the surgery, anaesthesia and diagnostic work.
While Medicare provides hip replacements with little or no out-of-pocket expenses for public patients in public hospitals, you may have to wait several months before receiving surgery. It's also worth remembering that you won't be able to choose your doctor if using the public system.
How to claim the Medicare rebate
You can claim your Medicare benefit using your Medicare online account accessible through myGov or your doctor. Because hip replacements can be so expensive, with prices varying from $19,439 to $42,007 depending on the surgeon, it's essential that you do this in order to avoid a substantial bill.
Average public vs private wait times in Australia for hip replacement surgery
Source: Australian Institute of Health and Welfare (AIHW) Private health insurance use in Australian hospitals 2006–07 to 2016–17
How does private health insurance cover hip replacement surgery?
If you go private, you'll have your choice of surgeon and hospital. There's a good chance you'll also have more say over when the surgery takes place.
To be covered, you'd need a private hospital policy, normally medium to high level. If you're getting joint replacement cover for the first time you'll also have to serve a waiting period of 12 months.
For the treatment, you're likely to receive out-of-pocket costs depending on things like your excess and what your doctor charges. That's why it's important to do your research beforehand.
What do different insurers offer for hip replacement surgery?
Below are some examples from Finder that cover joint replacement surgery. All quotes are based on a single hospital policy in Sydney with $500 excess.
deluxe silver plus
|Silver||$144.75||Go to Site|
Hospital Silver Plus
|Silver||$153.35||Go to Site|
Quotes are based on less than $90,000 income.
Health Insurance Reforms coming April 2019As part of the reforms to the Australian health insurance system, we will see hospital policies placed in four categories: gold, silver, bronze and basic.
Each of these tiers includes cover for a minimum number of clinical categories. If you wish to continue to claim benefits for hip surgery and replacement, you will need a policy of Gold tier.
How much will I be out of pocket?
The MBS fee for hip replacement as at November 2018 is $1,317.80. Individual costs do differ and the below chart shows the different benefit amounts paid by insurers on average for a hip replacement doctor's fee.
- Ahm: $2,000.75
- Bupa: $2,109.90
- HCF: $2,503.80
- Medibank: $2,000.75
- Nib: $2,024.25
- AHSA: $2,235.30
There are a number of things you can do to work out your own estimate:
- Call your surgeon to get their cost. The average cost of a hip replacement can vary by more than $20,000, so it's worth looking into.
- Ask if your surgeon is on your private health insurer's preferred list to help find the most affordable option.
- Ask for their extras cost as things like an anaesthetist can cost a lot.
- Make sure there are no hidden out-of-pocket expenses like X-rays.
- Ask for the Medicare code.
- Call your private health insurer and give them your Medicare code.
- Call the anaesthetist and ask for a cost estimate.
- Find out your doctor's estimated rebate.
What does hip replacement surgery involve?
There are two types of hip surgery: anterior, where an incision is made at the front of the hip and posterior, where the incision is on the side. Each surgery has a slightly different procedure:
- Anterior hip replacement is a minimally invasive approach associated with a faster early recovery for the patient.
- The procedure is performed under general anaesthesia and a small incision is made, usually between three and six inches long on the front of the thigh.
- The femur bone is then separated from the acetabular socket and any damaged cartilage and bone is removed and reshaped.
- The acetabular prosthesis is secured using special cement or screws and the femur is prepared using special instruments so that the new prosthesis fits perfectly into the bone.
- The procedure is performed under general anaesthesia: an incision is made close to the buttocks and the surgeon must part the muscle to gain access to the hip joint.
- A posterior total hip replacement replaces the femoral head and acetabulum with artificial prosthesis.
- In this case, the femoral head is removed and the femoral component is secured using cement or screws.
- Your surgeon will slide the femoral head into its acetabular counterpart.
How long is the recovery time for hip replacement surgery?
Typically, patients return to normal life activities within one to six months. The most discomfort ordinarily comes after surgery where you'll probably feel some pain but will receive medication to ease the discomfort. 24 hours after surgery you'll be given exercises and a walking aid, such as a stick, to get you moving and begin strengthening the muscles around the hip.
Short-term recovery involves getting off painkillers and managing to sleep without discomfort. You'll find you're on the road to recovery when you no longer need any walking aid and can move about the house without pain. It usually takes around four to six weeks to get to this stage of recovery.
Long-term recovery is when you can return to work and do normal, daily activities. You should also find that surgical wounds and soft tissue have healed, generally feeling normal again.
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