Will it be covered in Australia? Pain and orthopaedic procedures
General information only. Not medical, insurance or legal advice. Coverage rules and prices change, so confirm with your insurer or public health service (such as the NHS, HSE or Medicare) before booking, and ask your doctor whether a procedure is right for you.
Pick a procedure
Medicare
- As a public patient in a public hospital you are treated at no charge.
- Outside hospital, Medicare pays 85% of the MBS fee for specialist services. If a doctor bulk-bills, you pay nothing.
- As a private patient in hospital, Medicare pays 75% of the MBS fee and your insurer pays the rest of the schedule fee. Doctors can charge more, leaving a gap.
- The Medicare Safety Net lowers costs once your out-of-hospital gaps reach a threshold, which is set each year.
Private hospital cover: which tier?
| Clinical category | Minimum tier |
|---|---|
| Pain management (injections) | Bronze |
| Bone, joint and muscle (for example carpal tunnel) | Bronze |
| Joint reconstructions | Bronze |
| Back, neck and spine (including fusion) | Silver |
| Joint replacements | Gold |
| Pain management with device (for example spinal cord stimulators) | Gold |
Lower tiers may include some categories as options or on a restricted basis. Waiting periods can be up to 12 months for pre-existing conditions and 2 months for most other treatment.
Quick check
Coverage checker →
Pick your procedure and get the short answer on coverage in seconds.
Waiting times
The AIHW reported that half of patients were admitted from public elective surgery waiting lists within 45 days in 2024–25.
Tax and levies
The net medical expenses tax offset ended on 1 July 2019. Higher earners without private hospital cover may pay the Medicare levy surcharge of 1% to 1.5%, and Lifetime Health Cover adds 2% to premiums for every year you are over 30 when you first take out hospital cover.
If you are refused
- Ask your insurer which clinical category and policy rule applies, and get it in writing.
- If you can’t resolve it, the Commonwealth Ombudsman handles private health insurance complaints for free.
- Complaints about a health service go to your state’s health complaints body, such as the Health Care Complaints Commission in NSW or the Health Complaints Commissioner in Victoria.
Frequently asked questions
What level of private health insurance do I need for a knee replacement?
Joint replacements are only a minimum requirement of Gold hospital cover. Check your policy, as some lower tiers include them as an option.
Start at home with free routines
Exercise and staying active are part of most treatment plans, whether or not you have an injection or surgery. These free routines and printable sheets are a good place to start.
- Free exercise library (213 exercises with videos)
- Condition routines (back, neck, knee, hip and more)
- Free printable exercise handouts
A physiotherapist can tailor an exercise plan to you.
Sources
- privatehealth.gov.au: Overview of the health system
- privatehealth.gov.au: Out-of-pocket costs
- Services Australia: Bulk billing
- MBS Online: Medicare safety net thresholds from 1 January 2026
- privatehealth.gov.au: Product tiers
- privatehealth.gov.au: Clinical categories
- privatehealth.gov.au: Waiting periods
- AIHW: Elective surgery admissions continue to rise while wait times stabilise (December 2025)
- ATO: Medical expenses tax offset
- privatehealth.gov.au: Medicare levy surcharge
- privatehealth.gov.au: Lifetime Health Cover
- Commonwealth Ombudsman: Private health insurance complaints
- Health Care Complaints Commission (NSW)
- Health Complaints Commissioner (Victoria)
Last checked October 2026. Found something out of date? Email hello@protocolarchive.com.
This page explains how coverage usually works, using public Australian Government, insurer, ombudsman and clinic sources listed above. It is general information, not medical, insurance, financial or legal advice, and it does not recommend any treatment, policy or provider. Rules differ by policy and can change, so confirm with your doctor, your insurer or the hospital before you decide. Protocol Archive is independent and is not affiliated with Medicare, the Australian Government or any insurer.