Health Insurance for Elective Surgery and Waiting Lists in Australia

Published: April 5, 2018

If you’re planning knee replacement surgery, skin cancer removal, cataract extraction or to start IVF treatment chances are you’ll be added to an elective surgery waiting list. Because elective surgeries are deemed medically necessary but don't need to be done within 24 hours, you can expect to wait an average of 38 days.

Waiting times vary across states and territories, from 28 days in the Northern Territory to 54 days in New South Wales.

Elective surgeries in Australia are on the rise, increasing by 2.8% on average in the last year. According to the Australian Institute of Health and Welfare (AIHW), between 2016 and 2017 about 748,000 patients were admitted to Australian public hospitals for elective surgery.

Health insurance for elective surgery in Australia should in theory not have an impact on your waiting time, as it ought to be driven by clinical needs. However, despite Medicare’s ability to cover elective surgeries, excessively long waiting periods have become the norm. Private health insurance patients have long been known to have a shorter wait for elective operations in the public system.

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However, such instances where private patients receive non-emergency surgeries more quickly than public patients should not be the norm. Under the Australian health care agreement, the time a patient must wait for elective surgery should be reflected in their urgent need for care.

What is elective surgery?

Elective surgery is a medically necessary surgical procedure that is scheduled in advance and can be delayed for at least 24 hours. As it is not classified as an emergency, you will be placed on an elective surgery waiting list. Surgery is generally performed by a surgeon in an operating theatre or procedure room under some form of anaesthesia.

Elective procedure examples include, carpal tunnel release, surgical removal of the gallbladder, cataract extraction, total hip or knee replacement, removal of haemorrhoids, and hernia repair.

What is an elective surgery waiting list?

In public hospitals, an elective surgery waiting list refers to a list of patients registered to receive elective surgery. Your treating doctor usually determines how urgent your surgery is and will then assign you to one of the three elective procedure categories. The time you can expect to wait for surgery depends on the group you are assigned to.

Elective surgery categories and waiting times

Category Description Average Waiting Time Procedure Examples
1. Urgent
  • Has the potential to deteriorate quickly and become an emergency.
30 days
  • Prostate biopsy
  • Cholecystectomy
  • Mastectomy
2. Semi-urgent
  • Unlikely to decline rapidly.
  • Unlikely to become an emergency.
  • Causes pain, dysfunction or disability.
90 days
  • Tonsillectomy
  • Hysterectomy
  • Total hip replacement
  • Cataract extraction
3. Non-urgent
  • Unlikely to deteriorate quickly.
  • Does not present any threat of becoming an emergency.
  • Minimal or no pain, dysfunction or disability.
365 days
  • Septoplasty
  • Varicose veins treatment
  • Myringoplasty
  • Total knee replacement

Is elective surgery covered by Medicare?

Yes, Medicare covers elective surgeries which are considered medically necessary. However, you need to provide documentation from your doctor establishing that your surgery is required. After you’ve had a consultation with your surgeon, you will be put on the elective surgery waiting list determined by your urgency category.

Is elective surgery covered by Medicare?

Yes, Medicare covers elective surgeries which are considered medically necessary. However, you need to provide documentation from your doctor establishing that your surgery is required. After you’ve had a consultation with your surgeon, you will be put on the elective surgery waiting list determined by your urgency category.

Elective surgery waiting lists in Australia

All Australian states are experiencing waiting list problems because public hospitals can no longer meet the high demand for elective surgeries. In South Australia, patients wait an average of 1 week longer than expected, while in Tasmania 8.8% of people are waiting more than 365 days.

Possible reasons behind these long waiting times include Australia’s ageing population, longer life expectancy and the increase in the prevalence of conditions where elective surgery is the most appropriate treatment.

Waiting times for elective surgery by state

Above statistics are from the Australian Institute of Health and Welfare 2016 to 2017
Territory Expected Waiting Times
NSW 54 days
Victoria 30 days
Queensland 32 days
Western Australia 34 days
Southern Australia 39 days
Tasmania 45 days
Australian Capital Territory 46 days
Northern Territory 28 days

Frequently asked questions and answers

What is the difference between a medical procedure and surgery?

While the term surgery and procedure are often used interchangeably, they are not the same thing. ‘Surgery’ is technically a type of procedure that involves cutting into the skin. A ‘procedure’ is the general term that refers to any series of pre-defined steps that when followed should lead to the desired outcome.

Can I claim for cosmetic surgery if I have private health insurance?

Cosmetic surgery also referred to as aesthetic surgery, will not be covered by private health when it is not medically necessary to improve or maintain your health. Examples of elective cosmetic surgery include breast or buttock enhancements, dermal fillers, tummy tuck surgery and facelift surgery.

However, you should be able to claim from your private health insurance if the cosmetic procedure is medically required and has a Medicare Benefits Schedule (MBS) number.

These procedures include:

  • Surgery to remedy congenital abnormalities (e.g. cleft palate).
  • Surgery (i.e. skin grafts) to remedy severe burns.
  • Breast reconstruction after a mastectomy.
  • Facial reconstructive surgery following trauma.
  • Breast revision surgery for implant complications.
  • Restorative procedures that treat scarred skin.

Is breast augmentation covered by Medicare?

Breast augmentation purely for cosmetic reasons will not be covered by Medicare. However, if cosmetic breast surgery is needed, for example after a mastectomy, you could receive a Medicare rebate.  It’s important to discuss the potential for these rebates with your qualified plastic surgeon before scheduling the procedure.

Is a vasectomy considered elective surgery?

Yes, a vasectomy is seen as an elective surgery because wanting this permanent form of contraceptive is not urgent and neither is it medically necessary. A vasectomy is usually carried out by a urologist in either day surgeries, general hospitals, and family planning centres.

Does health insurance cover weight loss surgery?

Select private health insurers in Australia do cover some of the costs associated with medically necessary weight loss surgeries, for example, bariatric surgery. However, because the surgery is so complex and only recommended to a fraction of the Australian population the costs covered varies from insurer to insurer. You'll generally have to wait 12 months after purchasing your cover before you can claim.

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