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Private Health Insurance for Joint Replacements

Megan Fraser Fact Checked Updated: 27 November 2023
Types of Health Insurance

Living with pain can affect every aspect of your life. Your joints are fundamentally important in the functioning of your entire body. When these essential body parts are damaged due to environmental or personal factors, it can result in immense pain and lowered function. The cost of knee replacement surgery may vary based on your chosen service provider and health insurance coverage.

Knee and hip replacements are not the only joint replacements that one may need. Today, we will explore shoulder, ankle, hip, and knee replacement costs in Australia and how your health insurance coverage can assist in mitigating the costs.

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Key Facts

  • Joint replacement surgery is performed when every alternative method has proven ineffective at relieving pain and restoring function to the joint.
  • Numerous joint replacement injuries result from years of use, arthritis or disease. These surgeries range in price and require health insurance policies that cover their costs.
  • The benefits a patient will receive from the procedure will be an overall decrease in pain, an increased quality of life, increased function and regained movement.
  • Public patients see a decrease in overall costs but an increase in waiting time, whereas private patients see an increase in costs and a decrease in waiting time.

Understanding Joint Replacements

Joint replacements are usually conducted by an orthopaedic surgeon to lower a patient’s joint pain and increase the functionality of the joint. Some common joint surgeries include the spine, hips, shoulders, knees, wrists and elbows. Joints may become damaged by years of use, arthritis and disease. The surgery is done by removing the diseased or damaged parts of the joint and replacing them with artificial implants.

Although there are many different types of joint replacements, it is always best to seek professional help if you are suffering from constant pain or notice a decrease in the joint’s ability to function. Joint replacement is often used when alternative methods such as medicines, physical therapy and exercise prove insufficient to decrease the joint’s pain and assist its movement.

Knee Replacement

Types of joint replacements

How much does a joint replacement cost

Every surgery is different. Depending on the placement of the injury, the type of injury and the hospital of choice, your procedure may range in costs. Medicare and Private health insurance companies have created plans to ensure that policyholders receive the cost-related assistance to mitigate high payment rates. Knowing each surgery’s estimated cost is a good way  to gauge and understand the potential payments that may need to be made after your insurer has paid out according to the policyholder’s  agreement.

Compare the costs

Procedure NamePatient PaymentSpecialist FeesMedicare & Insurer PaymentTypical Hospital Fees
Knee Replacement$680$4,800$3,700 (M: $1,900, I: $1,800$18,000
Hip Replacement$690$5,000$3,800 (M: $1,900, I: $1,900)$20,000
Ankle Replacement$870$4,900$3,300 (M: $1,700, I: $1,600)$15,000
Shoulder Replacement$700$5,300$4,000 (M: $2,000, I: $2,000)$19,000

Source: Medicalcostsfinder.health.gov.au (October 2023; MBS Item(s) for Procedures 49518; 49321, 49318, 49715, 48918)

Joint Replacement

Navigating the Australian Healthcare System for Joint Replacements

There are two routes that a patient can go based on their personal circumstances. These two routes are public and private. It is essential to weigh the pros and cons of each and your current personal situation to make a decision that directly matches your needs.

In a public hospital, public patients will typically have lowered out-of-pocket charges for the surgery, but waiting time is exceptionally long, and the patient cannot choose their own surgeon. For private hospitals, it is the other way around. While it is more expensive, the waiting time is lowered.

The decision between public and private should reflect your current personal requirements. If you are in immense pain and urgently need the surgery, private is the best option. If you do not think your situation is direor if you can wait for your surgery, public is the best choice. Let’s look at the differences between the two to better understand how they affect joint replacement surgery.

Medicare and joint replacements

As previously mentioned, if you are a public patient in a public hospital and covered by Medicare, Medicare will assist you in covering the costs associated with the procedure. Patients across Australia covered with Medicare in a public hospital have no costs associated with the procedure because it is one of the procedures that Medicare provides direct cover.

Private health insurance coverage for joint replacements

The costs associated with receiving care in the private sector will vary based on your chosen plan. Across Australia, only 68% of patients had out-of-pocket costs; of this percentage, the average amount paid was $680. You must always discuss the costs involved in the procedure with your surgeon, hospital and private health insurance provider before the surgery to ensure that you understand and estimate what costs will and will not be covered.

Which type of health insurance covers knee replacement surgery?

Typically, Silver Plus and Gold level Hospital policies have sufficient coverage for joint replacements. In most instances, your private health insurance provider will explain the costs that will be covered during the procedure. Some costs to also note are hospital fees such as accommodation, theatre and medical devices. Depending on your chosen policy, you may have out-of-pocket fees for these costs, or you may have to make a co-payment.

Waiting periods for joint replacements

Data from the Australian Institute of Health and Welfare (AIHW) for 2015-2016 indicated that public patients waiting for knee replacement surgery waited an average of 200 days before their surgery, and those needing hip replacement surgery waited an average of 100 days before their surgery.

In a private hospital, private patients usually see an increase in costs for the procedure, which often means paying out-of-pocket (depending on your insurance policy) for any excess amount remaining after the insurance claim. While costs are higher, the waiting time is significantly lower than that of the public system, and patients canhave the ability to choose their own surgeon.

No-Gap Cover for knee replacements

Depending on your chosen policy and health insurance provider, you may not have to pay any out-of-pocket fees for your joint replacement surgery. No-gap is a type of cover often offered by health insurance providers to mitigate or clear any costs that exceed the base cover provided. Asking your health insurance provider about their no-gap coverage is another way to lower out-of-pocket payments.

Frequently Asked Questions and Answers

  • What is joint replacement surgery, and why is it needed?

    Joint replacement surgery is a procedure conducted by an orthopedic surgeon to reduce pain and return movement and function to a joint. The affected area of the joint is removed and replaced with an artificial part that acts the same as a regular joint would. The procedure is needed in cases where the patient may struggle with immense and continuous pain that cannot be treated with alternatives and when the diseased or damaged joint impedes movement and other functions.
  • What are the different types of joint replacement surgeries?

    There are various joint replacement surgeries, and each affected area will require a different type of surgery. These surgeries may include areas such as the spine, wrists, shoulders, knees, hips, ankles and elbows. Depending on the surgery type and the severity of the procedure, the costs involved may also change.
  • How do I know if I am a candidate for joint replacement surgery?

    You will be regarded as a candidate for joint replacement surgery if you experience continuous pain and continuous discomfort, if the joint feels unstable, if you struggle to perform simple acts such as walking up and down stairs and if you have great difficulty moving the affected area. You would also be regarded as a candidate for joint replacement surgery if you have attempted alternative treatments and noticed little progress. The procedure is often used after every other method has proven insufficient.
  • What are the risks and benefits associated with joint replacement surgery?

    Just like any surgical procedure, there are a few risks involved. These risks could include blood clotting, infection and loosening artificial replacements. The benefits of this surgery include a reduction in pain, regained movement, increased quality of life and increased activity level. For this procedure, the benefits far outweigh the risks, with fewer patients reporting drawbacks than benefits.
  • How should I prepare for joint replacement surgery?

    The best way to prepare for joint replacement surgery is to attend pre-surgery education classes that will assist you in completely understanding the procedure and what to expect, going to physical therapy to strengthen your joints and muscles before the procedure and improving your overall health. Improving your overall health will ensure a better surgery and improve the long-lasting bodily effects you may notice after the surgery.

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