Joint replacement health insurance

What is a joint replacement?

A joint replacement is surgery where a damaged joint - like a knee, hip, or shoulder - is replaced with an artificial one, usually made of metal, plastic, or ceramic. It's often done when arthritis or an injury causes too much pain and stiffness, making it hard to move. The goal is to reduce pain, improve movement, and help people get back to everyday activities.

Is joint replacement covered by Medicare?

Medicare will pay for all of the cost of a joint replacement in a public hospital. There should be essentially no out-of-pocket costs for the treatment, at least for essential services. The main downside of using the public system is that you'll have longer surgery wait times. In 2023–2024, wait times were around 135 days for a hip replacement and 265 days for a knee replacement.

How does private health insurance cover joint replacements?

Joint replacements can be covered in a private hospital with a private hospital insurance policy. You'll need to have joint replacements included in your cover - Joint replacement is covered by all gold-tier private hospital insurance policies but several silver plus policies will also cover you.

Remember - your private health insurance won't pay the entire amount. It covers all hospital and accommodation fees, as well as the cost of prosthetics that will live in your joints. It will then cover a decent chunk of the surgery fees, but there's often an out-of-pocket cost for the surgery itself, which can be pretty significant, in the thousands of dollars.

Cheap hospital cover for joint replacements

Joint replacements are an expensive surgery, generally costing over $20,000 all up. As a result, hospital insurance that covers joint replacements generally come with pretty high prices. The cheapest policies generally start around $40 a week.

As of the time of writing, the cheapest policy on Finder that covers joint replacements is ahm core silver plus, which will set you back around $39 a month*. While gold tier policies are the only policies that are mandated by the government to include joint replacements, this is one of the Silver Plus policies that includes it as well.

*For a single 30-year-old earning less than $105,000 a year in Sydney.

Cost of joint replacements with health insurance

The average out-of-pocket costs for privately insured joint replacements patients are listed below. This data comes from Medical Costs Finder, which is a great government resource that tracks these costs. As a private patient, the hospital costs are fully covered, and the out-of-pocket cost is the amount that you'd be paying on top of your insurance premiums and excess.

The prices above are averages, but they are based on thousands of real world operations. To find out the cost of your specific surgery, speak to your health fund, GP and any prospective surgeon before you get booked in. Part of their job is to get you an estimate of the final costs to you, which you should get in writing.

Health insurance waiting periods for joint replacements

When you get private health insurance that covers joint replacements, there is a 2-month waiting period before you can make a claim.

The one exception to this is if you have a pre-existing condition - you'll then need to wait for 12 months before you can claim. This will include conditions like arthritis, where you may not yet have had the recommendation to get a replacement, but there's been an underlying condition. The good news is that after that 12 month wait, you should be able to schedule surgery pretty quickly.

Public hospital surgery waiting times

If you use Medicare for a joint replacement in the public system, then you'll have to wait for your surgery to be scheduled. Unfortunately, there are lots of public patients that need joint replacements and waiting times average several months.

In 2023-2024, the wait time for a total hip replacement was around 135 days, while the wait time for a total knee replacement was 265 days. Going private can help you get surgery much sooner than this.

Frequently asked questions

• What health insurance do I need to cover joint replacement?

  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.

• Are joint replacements covered by Medicare?

  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.

• What's the difference between joint replacement and joint reconstruction?

  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 is a Gold-tier clinical category, but many silver plus policies also include it. Joint reconstruction is covered by bronze hospital cover.

• Is arthritis a pre-existing condition for joint replacement?

  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.

To make sure you get accurate and helpful information, this guide has been edited by Jason Loewenthal as part of our fact-checking process.

Written by

Tim Bennett

Insurance expert

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