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Joint Replacement Health Insurance

Name: Joint Replacement Health Insurance
Creator: Savvy
Published: 2023-04-14T16:42:16+09:30

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Written by , updated on July 6th, 2023

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If you're considering joint replacement surgery for either your hip, knee or shoulder, you may be wondering if your private health insurance covers the costs of the procedure. Joint replacement surgery is a complex procedure, and the bills can add up quickly if you don’t have adequate insurance cover.

This is where private health insurance may come in handy. You can find and compare online health insurance policies from a panel of health funds in one place through Savvy. All you have to do is answer a few simple questions and you could have health insurance policies to compare almost instantly. Get started today and compare health insurance policies through Savvy.

Is joint replacement covered by private health insurance or Medicare?

Joint replacement surgery is covered by Medicare if you have the procedure done in a public hospital. However, according to the latest report from the Australian Institute of Health and Welfare, almost 30% of patients on public health waiting lists had to wait more than a year for their surgery, with an average time of more than 250 days for knee replacement surgery and 153 days for a hip replacement in 2021/2022.

Due to these prolonged waiting times, many people use private health insurance to cover the expenses of their knee or joint replacement surgery and enable them to be treated more quickly in a private hospital or skip the queues in public hospitals.

Under Australian health insurance legislation, gold hospital cover is the only level of private health insurance which must provide cover for joint replacements. However, certain funds may offer similar coverage with their silver plus policies. If you opt to have your surgery as a private patient, Medicare will pay a portion of the costs, but you’ll have to cover the remaining expenses through your health insurance. Costs that can be covered by your private health insurance include:

Hospital admission fees
Private room fees
Theatre fees
Surgeons’ and anaesthetists’ fees
Tests performed while you’re an in-patient, such as blood tests and x-rays
Some allied healthcare services provided while you are an in-patient such as pain management and physiotherapy

You can compare either gold or silver plus health cover policies from our panel of insurers here through Savvy. Considering a wide range of options may help you find a reasonably-priced policy which can provide the best coverage for your knee, hip or joint replacement surgery.

How do I compare health insurance policies which cover joint replacements?

Some of the aspects to consider when comparing hospital cover health insurance policies that provide cover for knee and joint replacements include:

Cost – comparing a range of different policies will help you get an idea of the cost of policies at the silver plus or gold tier level. Of course, the cost will depend on factors such as the health fund you choose and the exact policy you buy. Most buyers will look to select one which is the most affordable, or fits within their budget, while at the same time providing maximum cover for joint replacements.
Excess – how much will you have to pay as an excess if you make a claim on your policy? You can choose the excess amount when you first buy your policy, with excess amounts of $250, $500 and $750 commonly available. However, you may be able to purchase a policy without an excess in some cases. The higher the excess you choose, the less your monthly premiums will cost.
Co-payments – check whether the policy requires you to make a co-payment for each night you're an inpatient in hospital. Some cheaper policies do require a co-payment, while more expensive policies may not require you to pay this additional out-of-pocket expense.
Inclusions and exclusions – check the documentation that comes with your policy so you know exactly what is and isn't included in the health cover policy you buy.
Waiting periods – look at the waiting periods which may apply before you can make a claim on the policy. If your need for a joint replacement is due to a pre-existing condition, such as arthritis, you may need to wait for 12 months before you can make a claim. However, if the reason for needing surgery isn’t due to a pre-existing condition, a two-month period may apply.
Special offers – some funds include ambulance cover as standard with gold or silver hospital cover policies. However, there are other special offers which may also be available, so it's worth comparing policies to find out if any of these are worthwhile for you.

Types of health insurance

Hospital cover

This can help you pay for medical treatment if you need to be admitted to hospital. It can help cover the cost of your admission or accommodation and the fees charged by doctors, surgeons and anaesthetists. It can also cover other costs associated with a stay in a private hospital.

Extras cover

This helps cover the costs of health care treatments outside a hospital setting which aren’t covered by Medicare. This can include major and minor dental treatment, orthodontics, hearing aids, physiotherapy, glasses, contact lenses and podiatry (in most cases with annual limits).

Cover for singles

This is a standard health insurance policy designed for a single person, rather than being tailored to cater to the needs of a couple or family. It may include hospital cover plus extras, or either of these types of insurance on their own, depending on what you're after for your health cover.

Cover for families

A family health insurance policy is designed for a family unit including dependent children who may reach up to 31 years of age with some insurers. It offers private health insurance suitable for the whole family and may include shared limits for all members included in your policy.

Cover for seniors

A health insurance policy aimed at seniors is designed to appeal to people who are in the second half of their life. These are often specific Silver Plus policies that offer the same cover as other health insurance policies, with the exception that pregnancy and childbirth cover may not be included.

OVHC

Visitors who are in Australia on a temporary basis for travel, work or study may be able to take out Overseas Visitors Health Cover (OVHC). Many visas issued in Australia come with a requirement to take out this type of insurance, which covers visitors who may not be covered by Medicare.

Ambulance cover

Ambulance cover is generally available either packaged into your private health insurance or on its own as a separate policy or subscription. By having this protection, you could be covered for all eligible ambulance travel in Australia (subject to your insurer's terms and conditions).

Basic hospital cover

The cheapest and most barebones form of private hospital insurance, this can include cover for rehab, in-hospital psychiatric services and palliative care. Having this policy will enable you to avoid paying the Medicare Levy Surcharge (MLS) and Lifetime Health Cover (LHC) loading.

Bronze hospital cover

Bronze hospital cover is a step up from basic insurance, including 18 further clinical categories such as ear, nose and throat, bone, joint and muscle, digestive system, joint reconstructions, gynaecology and chemotherapy, radiotherapy and immunotherapy for cancer.

Silver hospital cover

Silver hospital cover is the second-most expensive type of policy and offers the second-most clinical categories. On top of what's offered by basic and bronze cover, it also includes heart and vascular system, lung and chest, blood, hearing device implantation and dental surgery.

Gold hospital cover

The highest level of private hospital insurance available in Australia, gold policies can offer cover for pregnancy and birth, weight loss surgery, assisted reproductive services and insulin pumps on top of all the categories provided by silver, bronze and basic hospital insurance.

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Frequently asked questions about health insurance for joint replacements

What is the cost of getting a joint replacement in Australia?

As of April 2023, the cost of a knee replacement procedure can range from $15,000 to $20,000 if you’re treated as a private patient. For a hip replacement, the cost can rise to between $20,000 and $35,000. However, a significant portion of this cost may be covered by Medicare, as long as your need for the surgery is compliant with Medicare criteria for public funding.

What is the difference between joint replacement and joint reconstruction?

Joint replacement surgery involves removing the damaged joint entirely and replacing it with an artificial one. Such artificial joints are typically made of titanium alloys or special grades of polyethylene. Joint reconstruction, on the other hand, refers to surgical procedures that aim to restore the structure and function of a damaged joint using various techniques such as bone grafts, ligament repairs, and cartilage restoration.

What out-of-pocket expenses might I have after joint replacement as a private patient?

Even if you have gold or silver hospital cover insurance, it's likely that you'll still have to pay extra out-of-pocket expenses. Medicare may cover a certain proportion of the surgeon’s fees, for example, but there may still be a gap that applies that you’ll have to pay yourself (if your private health insurance doesn’t cover 100% of gap fees). However, the out-of-pocket expenses you’ll end up with may only amount to a few hundred dollars, depending on the exact health insurance policy you choose to buy.

Do I need extras cover health insurance as well as hospital cover for a joint replacement?

Having extras cover isn’t mandatory for joint replacement surgery, as knee or hip replacements performed as a private patient are usually covered by hospital cover policies. However, extras cover can help you pay for additional costs associated with the surgery, such as physiotherapy, occupational therapy or possibly even home nursing to help you recover after the surgery has been completed.

Can I choose my surgeon and hospital for a joint replacement if I have private health insurance?

You may be able to, depending on the facilities, expertise and surgeons available in your area. You’ll typically have more options for choosing your surgeon and hospital if you do have private health insurance, rather than opting to have your operation as a public patient. However, it’s important to first check with your health insurance provider to see if there are any specific limitations or requirements in terms of which doctor and facility are covered by your specific policy.

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