Key Takeaways
- Gold hospital policies always include joint replacements, with some Silver Plus policies also adding them.
- Your device/implant (prosthesis) attracts a mandated benefit when listed, but you’ll still have surgeon/anaesthetist gaps as well as any policy excess.
- Public surgery means longer wait times. Having private hospital cover means you’ll get your choice of surgeon and (in most cases) faster bookings once your waiting periods have been served.
Your guide to hospital cover for knee and hip replacements
Choosing hospital cover for a knee or hip replacement is less about guessing the ‘best’ health fund and more about matching your policy to the right category – and knowing how real-world costs actually work. So we’ve put together this simple breakdown so you can avoid all of those nasty surprises and embrace your surgery without any unnecessary stress.
Which policies actually cover replacements?
Hospital cover is organised into Basic, Bronze, Silver and Gold tiers, with standardised clinical categories that decide what’s in or out. Joint replacements (hip/knee replacements, revisions, resurfacing and related items) is a category that you’ll always find on Gold hospital cover. Some insurers also include joint replacement cover on Silver Plus policies (a Silver policy that has extra categories above the minimum).
Here’s an important distinction though: ‘joint reconstructions’ (think ACL repairs, shoulder stabilisations, etc.) are not the same as ‘joint replacements’ (hip or knee arthroplasty). If you need a total knee or hip replacement, your policy has to include the joint replacements category – not just reconstructions.
What type of insurance covers knee and hip replacements?
- Hospital cover for knee replacement/hip replacement sits under the ‘joint replacements’ category.
- Gold policies include it by default. Some of the top Silver Plus policies will include it as well.
Why hospital cover helps (aside from tax)
The public system here in Australia delivers truly excellent care, but elective joint surgery has long queues. Recent reporting of AIHW data shows the median public wait for total knee replacement is around 265 days and 135 days for total hip replacement – which is still many months of pain and limited mobility. With a good amount of hospital cover and once your waiting periods are served, you can usually pick your surgeon and book in sooner in a private hospital.
What does your cover actually pay for?
- Hospital costs (accommodation, theatre, some devices).
- Specialist fees (orthopaedic surgeon, anaesthetist, surgical assistant, sometimes physician).
If you have eligible hospital cover that includes joint replacements, your fund helps with private hospital costs, while Medicare plus your insurer together pay at least the MBS benefit towards specialist fees. Where a doctor charges above the MBS, you can be slapped with a gap fee – unless they use your fund’s no-gap/known-gap scheme.
Implants and the ‘Prostheses List’ (now the ‘Prescribed List’)
For devices like hip and knee implants, insurers have to pay benefits when the device is on the government’s Prescribed List of Medical Devices and Human Tissue Products and the policy covers the procedure. That means no out-of-pocket for standard, listed implants themselves – but you can still have gaps from surgeons/anaesthetists, excesses or non-device hospital charges.
Portability
Don’t re-serve waiting periods when you switch to a new health fund or policy
“John was immediately covered for a hip replacement in private hospital because he had already served his waiting periods for joint replacements on his old policy”
The money question
An unfortunate reality is that surgeons set their own fees. Two helpful, government-run sources paint the picture:
- On Medical Costs Finder (knee replacement), most privately insured patients in a private setting had some out-of-pocket specialist costs. Around 82% had a gap (varies by state and doctor), and the typical specialist out-of-pocket was around ~$1,000 (not including any policy excess).
- For hips, the pattern is similar. Medicare and your fund will cover the MBS portion, but around 84% will still end up owing out-of-pocket costs if your specialists charge above that.
A good rule of thumb? Even with the right joint replacement cover, budget for your excess, any specialist gaps, potential assistant/anaesthetist fees, as well as physio/rehab afterwards (claimed under extras).
5 essentials to check before you upgrade (or book)
- Is joint replacements included? Don’t rely on product names – open the brochure and double-check the clinical category. If it’s Silver Plus, check that joint replacements is definitely ticked.
- Waiting periods: If your osteoarthritis or hip dysplasia is already symptomatic, most funds have a 12-month waiting period for pre-existing conditions on hospital benefits. If you upgrade from a policy without the category to one with joint replacements, that 12-month wait will only apply to new benefits.
- Excess and co-payments: A lower excess means higher premiums (and vice-versa), so pick an excess you can afford at admission. If you’re also managing the Medicare Levy Surcharge, make sure your excess sits within the ATO’s limits for a policy to count as ‘appropriate’ hospital cover.
- No-gap/known-gap arrangements: Ask your surgeon and anaesthetist whether they are part of your health fund’s gap scheme. If they do, your out-of-pocket can drop dramatically. If not, you’ll pay the difference between their fee and the MBS/insurer benefits. Get it in writing before you commit.
- Agreement hospitals: Check your fund’s contracted hospitals near you. Agreements influence theatre/accommodation charges and can impact your bill, even when your policy includes joint replacement cover.
Hospital cover for knee replacement versus hip replacement
From an insurance standpoint, both are within the joint replacements category. The nuances tend to be clinical (your surgeon’s technique, implant choice, etc.) rather than insurance. For both, you’ll want:
- The right tier (Gold or appropriately configured Silver Plus).
- A comfortable excess and total clarity on gaps.
- A plan for rehab/physio – usually extras benefits (waiting periods and annual limits apply).
Public versus private – what you’re trading
With public, there’s no payment for the operation itself as a public patient, but you don’t get to choose your surgeon, and knee replacements in particular can involve long waits.
With private hospital cover, you get your choice of specialist, faster times to book in surgery and, of course, a private hospital setting. You’ll still handle any excess and possible gaps – which you can reduce by choosing gap-scheme doctors and going with hospitals in your health fund’s network.
Some pitfalls to avoid
- Mixing up reconstructions with replacements: If the joint replacements category isn’t covered, your hip or knee arthroplasty won’t be either.
- Upgrading too late: The pre-existing rule can make a last-minute upgrade unhelpful, so start early.
- Assuming implants means no costs at all: The device might be covered via the Prescribed List, but specialist gaps/excesses are separate.
- Ignoring the gap scheme: Most out-of-pocket shocks are avoidable if you actively choose no-gap/known-gap doctors.
Conclusion
If your surgeon has mentioned knee or hip replacement, you need a policy that explicitly includes the ‘joint replacements’ clinical category. In practice, that’s Gold hospital cover – or a high-quality Silver Plus policy. Then, de-risk the money side by confirming any waiting periods, picking an excess you can live with, choosing gap-scheme providers and agreement hospitals, as well as planning rehab through extras (if you’ll use it).
Fair Health Care Alliance can walk you through and compare hospital policies that include joint replacement cover – giving you what you need in plain English, without the fine-print headaches.
FAQ's
Not under standard rules. Joint replacements are not a Bronze minimum. You’ll need Gold or a Silver Plus policy that includes joint replacements.
Hospital benefits for pre-existing conditions can have a 12-month waiting period (two months for most other hospital services). Plan early if your surgery is likely.
If the device is on the government’s Prescribed List and your policy covers the procedure, your fund has to pay a benefit for it. Gaps can still crop up from specialist fees or your excess.
