Cataract surgery and hip and knee replacements become increasingly relevant as we age. What you pay, how long you wait and whether your health insurance helps can depend on choices made years earlier.

There is a conversation that happens in plenty of Australian households somewhere between 65 and 80. A specialist says the word “eventually”, and eventually turns out to be sooner than expected.

Cataract surgery. A hip replacement. A knee replacement.

These are established procedures performed on thousands of Australians every year. Cataract extraction alone was the most common procedure for patients admitted from public hospital elective surgery waiting lists in 2024–25.

They are also procedures where the difference between one health insurance policy and another can suddenly stop being a line in a brochure and become very real.

So what might you pay, how long could you wait, and what does your cover actually change?

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What they cost

The first thing to understand is that the cost of surgery is rarely one neat number.

As a private patient, you may encounter fees for your surgeon, anaesthetist and other specialists, as well as hospital charges such as accommodation and theatre costs. Depending on the procedure and your cover, prostheses, medicines, imaging, physiotherapy and other services can also form part of the overall cost.

Medicare and your private health insurer may cover some or all of those costs, depending on the service and your policy. For in-hospital medical services covered by Medicare, Medicare generally pays 75 per cent of the Medicare Benefits Schedule fee and the insurer at least 25 per cent. Doctors can charge above the schedule fee, however, which is one way a gap can arise.

That is why someone can be told they are “covered” and still face an out-of-pocket bill.

The Australian Government’s Medical Costs Finder is a useful starting point. It shows typical fees and out-of-pocket costs for available specialist services and lets you search by location. The government cautions that it is a guide, not a quote for what your treatment will cost.

Australian Government Medical Costs Finder

The important point is that you can investigate many of these costs before agreeing to surgery.

Ask your specialist what they will charge and whether other doctors, including an anaesthetist, will bill separately. Ask the hospital about its charges. Then ask your insurer what it will pay and what could be left for you.

That can prevent a nasty surprise after you come home.

How long you wait

In the public system, cataract surgery and hip and knee replacements are classified as elective surgery.

“Elective” can sound like “optional”. It isn’t. AIHW defines elective surgery as planned surgery that can be booked in advance following a specialist clinical assessment. It can still be medically necessary and urgent.

And waits can vary enormously.

In 2024–25, half of all patients admitted from Australian public hospital elective surgery waiting lists received their surgery within 45 days. But that overall figure hides much longer waits for some procedures.

For cataract extraction, the national median was 106 days. In other words, half of patients waited longer. In outer regional areas, the median cataract wait was 155 days.

Across all elective procedures, 6 per cent of patients waited longer than a year in 2024–25.

Your own wait will depend on the procedure, clinical urgency, hospital and where you live, so national figures are a guide, not a prediction.

There is another option people sometimes overlook: being treated as a private patient in a public hospital.

If you have appropriate private hospital cover, you can choose to be treated privately in either a public or private hospital. A private patient can generally choose their doctor but, unlike a public patient, may face charges for their care.

Don’t assume using your insurance in a public hospital automatically means jumping the queue. Ask the hospital and your insurer what it would actually change in your circumstances.

The part that catches people out: your tier

Australia’s hospital policies are classified as Basic, Bronze, Silver or Gold, with minimum clinical categories attached to each tier. Policies can also be sold as “Plus” products when they include additional categories above the minimum requirements for that tier.

Here is the important part.

Cataracts and joint replacements are both mandatory categories under Gold hospital cover. Standard Silver, Bronze and Basic policies are not required to cover them.

A Silver Plus policy, however, may include one or both. Some do; others don’t.

A policy can also provide restricted cover for some clinical categories. Restricted cover may leave you facing significant costs if you choose private treatment, so “restricted” deserves just as much attention as “excluded”.

That creates a situation worth avoiding: paying for private hospital insurance for years, then discovering when surgery is recommended that your particular policy doesn’t include it.

You can check this before anything is wrong.

Three questions to ask your insurer:

1. Is joint replacement fully covered, restricted or excluded?
2. Are cataract and lens procedures fully covered, restricted or excluded?
3. What excess, co-payment and other out-of-pocket costs could apply if I were admitted tomorrow?

Why “I’ll upgrade when I need it” can backfire

This is where timing matters.

When you take out hospital insurance or upgrade to a higher level of cover, an insurer can impose waiting periods before you receive the new benefits.

For hospital treatment involving a pre-existing condition, the maximum waiting period is 12 months. For most other hospital treatments, the maximum is two months.

And “pre-existing” does not necessarily mean you already have a formal diagnosis.

Under the rules, it can include an ailment, illness or condition where signs or symptoms existed during the six months before you joined or upgraded. The assessment is made by a medical practitioner appointed by the insurer, taking information from your treating doctor into account.

So waiting until a knee, hip or cataract is already causing trouble before checking your cover may leave you facing a waiting period if you upgrade.

The better time to understand what your policy includes is before you need to use it.

What this all adds up to

None of this means everybody over 65 needs Gold hospital cover. Gold can be expensive, and the right level of insurance depends on your circumstances, priorities and budget.

But if one reason you continue paying for private hospital insurance is to have options should you eventually need cataract surgery or a hip or knee replacement, it is worth confirming that your policy actually provides that cover.

Don’t rely on the colour of the policy alone. Look at the clinical categories.

Five minutes spent checking now could save a much more difficult conversation later.

Not sure what tier you’re on or what it includes? You can compare your hospital cover with Starts at 60, or speak to an Australian adviser on 1800 31 23 60. There is no obligation to switch. Checking what you already hold is a perfectly good reason to call.

Have you had cataract surgery or a hip or knee replacement? What did you pay, and how long did you wait? Tell us about your experience in the comments.

Worth knowing where you stand?

You can compare your health insurance with Starts at 60, or talk it through with an Australian adviser on 1800 31 23 60. There is no obligation and no pressure to switch – plenty of people call simply to find out whether their current cover still stacks up.

We’ll be following the legislation through to the Senate committee report in October and will come back to what it means from there. If you have a question about your own situation, leave it in the comments below. We read them, and they help shape what we cover next.

ALSO CHECK OUT What Medicare covers after 60 and the five gaps that catch people out

IMPORTANT LEGAL INFO This article is of a general nature and FYI only, because it doesn’t take into account your personal health requirements or existing medical conditions. That means it’s not personalised health advice and shouldn’t be relied upon as if it is. Before making a health-related decision, you should work out if the info is appropriate for your situation and get professional medical advice.