Hip and knee replacements are among the most common surgeries in Australia, and given how prevalent joint problems become with age, there’s a good chance you or someone close to you will need one eventually. But here’s an uncomfortable truth: most people don’t actually know what their health insurance will cover until they’re already booked in for surgery — and by then, it’s too late to shop around.

The real cost of a joint replacement

According to Australian Government data, the total cost of a knee replacement in a private hospital – factoring in specialist fees and hospital fees – comes to roughly $23,000. Hospital fees alone typically run to around $18,000 to $20,000, with specialist fees adding a further $5,000-plus. Without private health insurance, self-funding a hip or knee replacement in a private hospital can run anywhere from around $19,000 to $42,000, depending on the complexity of the case and length of stay.

Not every policy covers it

Here’s the part that catches people out: hip and knee replacements are only guaranteed to be included in Gold-tier hospital policies (or in some cases Silver Plus products). If you’re on a Basic, Bronze or standard Silver policy, there’s a real chance you’re not covered for this procedure at all – meaning you’d either need to upgrade your policy (and serve a new waiting period, typically 12 months for pre-existing conditions) or pay the full cost yourself.

Even with the “right” cover, gaps are common

Even for those with appropriate Gold-level cover, out-of-pocket costs are still the norm rather than the exception. Your health fund and Medicare together typically cover the hospital fees and the joint prosthesis itself (which is covered in full for standard implants under the federal Prescribed List). But your surgeon, anaesthetist and any surgical assistant set their own fees – and where those fees exceed the combined Medicare and health fund benefit, you pay the difference.

Government data-based estimates put the typical out-of-pocket gap for a privately insured patient’s medical fees at around $1,000 per joint, though this varies significantly depending on your surgeon and your fund. Notably, the AMA’s Private Health Insurance Report Card has found your benefit can vary by as much as 7 per cent for the same knee replacement, purely depending on which insurer you’re with — a meaningful difference when the total bill runs into the tens of thousands.

The no-gap alternative

Some funds have moved to close this gap altogether. Several major insurers now run “no-gap” joint replacement programs with participating hospitals and surgeons, where eligible members pay no out-of-pocket medical costs at all for hip and knee replacements (excess still applies). These programs aren’t available everywhere, and typically require you to have held appropriate hospital cover with that fund for a set period – often 12 months – before you’re eligible. If your current fund doesn’t offer this and a competitor does, that’s a genuinely significant difference worth knowing about before you need surgery, not after.

Why this is worth checking now, not later

Waiting periods mean you can’t simply upgrade your policy the week before surgery and expect it to be covered. If joint pain is something you’re already managing, or simply something you’re conscious of as a common issue with age, checking now whether your current policy actually includes joint replacement – and how generous your fund’s gap cover is compared to others – could save you thousands of dollars down the track.

Want to know if your current policy actually covers joint replacement, and how the gap compares to other funds? Compare your health insurance with Starts at 60 to see your options.