Private Health Insurance? Costs of Surgery
Private Health Insurance in Australia: What Patients Need to Know Before Orthopaedic Surgery
When you’re considering orthopaedic surgery—whether it’s a knee replacement, hip replacement, or arthroscopy—one of the biggest questions is: “Should I use private health insurance or stay in the public system?”
As an orthopaedic surgeon practicing in Australia, I often help patients understand the role private health insurance plays in their care. Here’s a clear breakdown of what you need to know.
Why Consider Private Health Insurance?
Australia has an excellent public healthcare system through Medicare, but private health insurance can offer important advantages:
✅ Shorter Waiting Times
Public hospital waiting lists for elective orthopaedic procedures, such as joint replacements, can be several months (sometimes over a year). With private health insurance, surgery can often be scheduled within weeks.
✅ Choice of Surgeon and Hospital
In the public system, you usually can’t choose your surgeon. With private health insurance, you can select the orthopaedic surgeon you trust and the hospital where you’d like to be treated.
✅ Private Room and Comfort
Private patients often have access to private or semi-private rooms, which can make recovery more comfortable.
What Does Private Health Insurance Cover for Orthopaedics?
Most hospital cover policies in Australia include orthopaedic surgery under “Joint Reconstructions” or “Joint Replacements” category. However, the level of cover matters.
Joint Reconstruction does not include Joint Replacement or joint arthroplasty. You need to be covered for JOINT REPLACEMENT to have a total knee replacement or total hip replacement.
Here’s what to check:
Hospital Cover Tier: Bronze, Silver, and Gold tiers vary. Gold usually includes joint replacements and revision surgery.
Excess & Gap Fees: Even with insurance, you may pay an excess or a gap fee (the difference between what your surgeon charges and what your insurance covers).
Prosthesis Coverage: Hip and knee implants are fully covered under the federal prosthesis list, so you won’t pay extra for standard implants.
Extras Cover: Physiotherapy and rehab often fall under extras cover, not hospital cover.
Further information is available here:
https://www.privatehealth.gov.au/health_insurance/howitworks/producttiers.htm
How Much Are Gap Fees?
Gap fees can vary between surgeons and hospitals. Some orthopaedic surgeons participate in “no-gap” or “known-gap” arrangements with health funds, meaning your out-of-pocket costs are reduced. Always ask for a written quote before surgery.
What About Self-Funding or Public System?
Public System (Medicare): No direct cost for surgery, but waiting times are long, and you can’t choose your surgeon.
Self-Funded Surgery: Some patients pay out of pocket for surgery in a private hospital. This can cost $20,000–$40,000 for a hip or knee replacement without insurance.
Private Insurance: Provides a balance between cost, speed, and choice.
Tips for Patients Considering Surgery
Check Your Waiting Periods
Most funds have a 12-month waiting period for pre-existing conditions like osteoarthritis.Understand Your Policy
Confirm that joint replacements or reconstructions are included.Ask for a Cost Estimate
Always request a detailed written estimate, including surgeon, anaesthetist, assistant, and hospital fees.Consider Rehabilitation
Plan for physiotherapy and rehab, whether at home or in a rehab facility.
Dr Collins’ Fees:
Dr Collins is a known-GAP or NO Gap provider for most insurance providers.
If you have BUPA or Medibank Private insurance, Dr Collins is an excellent choice as one of Melbourne’s top knee and hip surgeons who can offer NO Gap/No out of pocket inpatient surgery costs.
Dr Collins is a registered specialist provider for all known health funds.
Here are the major private health insurance providers in Australia:
Big National Health Funds
Bupa
Medibank (including ahm)
HCF (Hospitals Contribution Fund)
NIB
Not-for-Profit and Regional Funds
HBF (Western Australia)
Teachers Health
Defence Health
CBHS Health Fund (Commonwealth Bank Health Society)
Police Health
RT Health (Rail, Transport)
Health Partners
Phoenix Health
TUH Health Fund (Teachers Union Health)
Smaller or Specialist Funds
Qantas Health Insurance (powered by nib)
Frank Health Insurance
Australian Unity
Peoplecare
GMHBA (Geelong Medical & Hospital Benefits Association)
Doctors’ Health Fund
CUA Health (merged with HBF in 2021)
OneCare
ACA Health
Transport Health
Final Thoughts
Private health insurance in Australia can make a big difference in your orthopaedic journey—offering faster access, choice of surgeon, and more comfortable recovery. However, it’s important to understand the costs, waiting periods, and what your policy covers before committing to surgery.
If you’re considering a hip or knee replacement, or another orthopaedic procedure, speak with Dr Collins and his team about your options.
