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Joint replacements and your health insurance

grandpa and granddaughter borderWhat is joint replacement surgery?

Joint replacement surgery involves removing a damaged joint and replacing it with an artificial prosthesis. A joint is where two or more bones come together, for example the knee, hip or shoulder. The surgery is performed by a specialist doctor called an orthopaedic surgeon, and can be covered by your health fund if you have the correct level of health insurance cover.

Replacing a joint can relieve pain, greatly improving your quality of life. Sometimes it may not be necessary to replace the entire joint but only the damaged parts. A joint replacement may be required as the result of injury or disease, but is often the result of arthritis. 

Read more about managing arthritis

Your doctor will conduct a series of tests before determining whether you need a joint replacement, and will most likely advise the use of exercise, walking aids, physical therapy or medication first, depending on the severity of the damage.

In severe cases, a joint replacement may be the only solution if you suffer form chronic and constant pain which impacts on your day to day life, for example if you experience difficulties with everyday activities such as walking, climbing stairs or taking a bath.

When taking out hospital cover, there are three different types of joint replacement features to select from, each covering different joint areas. They are hip, knee, and shoulder / elbow. Other joints not mentioned will usually be covered as a matter of course, but you should check with your health fund.

What happens during and after surgery

Each surgery performed on a joint will vary from person to person. Generally a hip or knee joint replacement may take about two hours to complete, depending on on how damaged your joint is and whether there are any complicating factors.

An anaesthetic will be administered before the procedure. The prosthesis used for the procedure will be tailored to your specific requirement. After your surgery a physiotherapist may see you to show you a variety of exercises to help you with your recovery.

In some cases you may be referred to a Rehabilitation Unit as part of your inpatient care.

Rehabilitation involves a specialised team comprising of a rehabilitation specialist, rehabilitation nurse, physiotherapist and occupational therapist, working together to ensure  you will become mobile enough to return to your normal day to day activities.

Depending on your surgery, you may need to remain in hospital for one to two weeks. If you are eligible to complete your inpatient treatment at home, you may be discharged from hospital earlier and receive care and treatment in your home. This is usually covered under your health fund's broader health programs, so you will need to check your eligibility with them.

It is important that you follow your doctor's advice on nutrition, exercise and medication after you have been discharged, as the recovery process is very important to the success of your surgery.

Joint replacement is usually very successful, however if there are any complications, your doctor will oversee your treatment to deal with these issues when they arise.

Health insurance cover for joint replacement surgery

All health funds provide cover for joint replacement, but you must ensure that you select a health insurance policy that provides full cover for the type of joint replacement surgery you may require. You can choose three individual features: hip joint replacement, knee joint replacement, and shoulder and elbow joint replacement. All other joints are generally covered.

Your health insurance policy may provide full cover, partial cover or no cover for these features. It it up to you to ensure that you select the correct level of cover. Also, remember that if the surgery is required as the result of a pre-existing condition, you will have a 12 month waiting period to serve before you are eligible to receive benefits.

Who pays for what?

When you undergo any of these procedures as a private patient, Medicare will pay 75% of the Medicare Benefits Schedule (MBS) fee for each MBS item provided as part of your treatment. Your health fund will pay the additional 25%. With private health insurance, you may choose your own doctor at any public hospital for the procedure, or at an agreement private hospital, provided that your level of health cover allows for private hospitals (most except the cheapest hospital covers do).

Usually, the prosthesis required for the joint replacement will be available to the patient at no gap. However, in some cases  your surgeon may prefer to use a more expensive prosthesis which will attract a gap. In these instances, you will need to pay the gap amount.

If your doctor charges above the gap, you may have to pay the extra amount, unless your health fund can provide extra benefits to help cover this gap. Many health funds have agreements with doctors who are willing to participate in the fund's “gap cover scheme”.

Remember in most cases there will be more than one doctor involved in your treatment. Along with your orthopaedic surgeon, you can also also expect an anaesthetist, assistant surgeon, radiologist and pathologist to take part in your surgery. In most cases you will also be required to see a physiotherapist and occupational therapist to assist with rehabilitation, as part of your in patient treatment.  Each will have their own bill, so it is important to find out about the charges associated with each specialist.


In some cases, the prosthesis may wear out or move, resulting in the requirement of another surgery. This is called a revision, and as long as your health cover has been maintained, you will be covered in the same way by your health fund as you were with your original joint replacement.

What's covered

Provided that your health fund has an agreement in place with the hospital where you will be receiving your treatment, doctor's fees, theatre and accommodation costs will be covered. You are entitled to, and should ask from your doctor an estimate in advance of the entire cost of the procedure so you know in advance if there will be a gap.

It should also be noted that any additional physiotherapy, which you may be required to have once you have been discharged from hospital, will not be covered as part of your hospital cover. To have your health fund pay a benefit for these services, you should ensure that you have extras cover that includes physiotherapy as part of its policy.

PPlease note: This information is provided as a general guide only, and should not be used as a substitute for advice provided by a medical professional or your health fund. We highly recommend you consult a doctor if you are concerned about your health, and speak with your health fund for specific health insurance-related queries.

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