Best private health insurance for joint replacement

Joint replacement surgeries like knee and hip replacements are common procedures that many Australians need, especially as the population ages. They can restore mobility and minimise persistent problems like chronic pain, but they come at a cost – and quite a pricey one.

While Medicare does cover some of the cost of joint replacements, the public system has its limitations – the biggest of which are surgery waiting periods. Private health insurance is an alternative that can get you in and out of the hospital faster, but knowing which health insurance policy to get can be overwhelming.

Let’s dive into the costs of knee and hip replacement surgeries and whether using the public or private healthcare system is the right choice for you.

Knee replacement surgery is often needed if you're suffering from severe arthritis or joint damage. The cost of knee replacement surgery will obviously depend on whether you choose to go through the public or private healthcare system.

• Public system: If you get knee replacement surgery in a public hospital using Medicare, the cost is fully covered. However, you will face long waiting times, which can be a downside (more on this later).
• Private system: In the private system, the cost of knee replacement surgery can easily jump into the tens of thousands of dollars depending on the hospital, surgeon fees and other factors. Medicare will cover 75% of the Medicare Benefits Schedule (MBS) listed fee, but the remaining costs, including gaps for surgeons, specialists, and prostheses, will need to be covered by you out-of-pocket or through private health insurance.

Private health insurance can help with these costs, especially if you have a Gold-tier hospital policy or a Silver-plus policy that includes cover for joint replacements. You’ll also get things like hospital accommodation, theatre fees, in-hospital pharmaceuticals and the prostheses used in the surgery at least partially covered.

Even with private health insurance, be aware that you’ll still be on the hook for some out-of-pocket costs, so make sure you discuss these potential costs with your health insurer, GP and surgeon beforehand.

Hip replacement surgery is another major procedure used to alleviate pain and improve mobility, especially for those managing arthritis or hip joint damage.

• Public system: Medicare covers the full cost of hip replacement surgery in a public hospital. But as with knee replacements, long wait times can be a big drawback for those relying solely on the public system.
• Private system: The cost of a hip replacement in the private system can once again surge into the tens of thousands of dollars. And just like knee replacements, Medicare will cover 75% of the MBS-listed fee, with the remaining costs to be managed either by your private health insurance or out-of-pocket payments.

To minimise your out-of-pocket costs, make sure you compare health insurance policies that offer solid joint-replacement cover. Some insurers might also have gap-cover agreements with certain hospitals or surgeons to further reduce any additional costs.

Yes, joint replacement surgeries are covered by Medicare, but the extent of the cover depends on whether you use the public or private healthcare system.

• Public hospital coverage: Medicare will cover 100% of the cost for joint replacement surgeries, including knee and hip replacements if performed in a public hospital. This means you’ll only have minimal out-of-pocket costs. The main downside of relying on the public system is the long waiting periods for surgery, which can stretch into several months or even years.
• Private hospital coverage: In the private system, Medicare will cover 75% of the MBS-listed fee for the surgery. So while some of the cost is covered by Medicare, you’ll still need to pay the remaining amount yourself or through your private health insurance. For example, the MBS-listed fee for a hip replacement could be around $1,900, but the actual cost of the surgery can be upwards of $20,000, leaving a big gap.

Private health insurance will bridge this gap by covering costs like your hospital accommodation, theatre fees and prostheses. However, it’s important to note that not all health insurance policies cover joint replacements, so make sure you do your research before choosing an insurer.

There are two types of waiting periods to be aware of: health insurance waiting periods and public hospital surgery waiting times.

When you first take out a private health insurance policy that covers joint replacements, you’ll need to serve a waiting period before you can make a claim.

• For most people, there’s a standard two-month waiting period for joint replacement surgery if it’s not related to a pre-existing condition.
• If you do have a pre-existing condition like arthritis, the waiting period balloons out to 12 months before you can make a claim.

If you're planning to switch from one insurer to another, make sure you check whether your new insurer will recognise the waiting periods you've already served.

Arguably the biggest drawback of getting joint replacement surgery through the public system is the long wait times.

• In 2021–22, the average wait time for a hip replacement in the public system was 153 days.
• For a knee replacement, the wait time was even longer at 293 days.

These long wait times are partly due to the high demand for joint replacements and the strain on the public healthcare system, particularly following the pandemic. In contrast, having great private health insurance will greatly reduce your waiting time for surgery. Private patients usually have much shorter wait times so they can get their joint replacement surgery done faster and return to full mobility sooner.

Choosing the best health insurance for joint replacement surgery can save you both time and money. While Medicare covers the full cost of surgery in the public system, private health insurance will get you in and out faster while also covering a portion of your expenses. Just make sure you compare your options and think about any potential out-of-pocket costs you might have to manage yourself.