Which pathway applies to you?
Which pathway applies depends mainly on whether your problem came from an injury or from wear and tear:
- Injuries and fractures are generally ACC. Treatment for accident-related injuries is generally covered by ACC, although surgery usually needs ACC approval first.
- Arthritis and elective joint replacement are generally not ACC. The options are the public system, private health insurance, or self-funding.
The two are not always clear cut. It is common for ACC to cover one part of the process and for insurance or self-funding to cover another.
Injuries and fractures: how ACC works
If you have an accepted ACC claim, ACC generally contributes to the cost of your specialist assessment. That is the straightforward part. Acute trauma is managed urgently as needed, and funding is sorted out alongside the treatment rather than ahead of it.
Approval for planned surgery is a separate step and it is not automatic.
This is the thing most people are surprised by. If Dr Hoskins recommends an operation, an application for approval is made to ACC. ACC then assesses whether the surgery is needed because of the covered injury, as opposed to a pre-existing condition such as degeneration that was already there. That assessment takes time and the answer is not always yes.
ACC may also contribute to:
- Physiotherapy and rehabilitation
- Weekly compensation for lost earnings, if you cannot work because of the injury
- Home help or equipment, depending on your circumstances
Even where ACC approves surgery, there can be a shortfall between what ACC pays and the full cost. You will be told about any expected shortfall before you commit to anything.
If ACC declines the application
That is not the end of it. The usual options are:
- Provide further information and ask ACC to review the decision
- Formally request a review of the decision, which is your statutory right
- Use private health insurance instead, if your policy covers it
- Self-fund the surgery
- Be referred into the public system
Arthritis and elective joint replacement
Osteoarthritis is wear in the joint rather than the result of an accident, so joint replacement for arthritis is generally not funded by ACC. There are three routes:
- The public system. Publicly funded joint replacement is available through the public hospital service, which has its own eligibility criteria and waiting times. Your GP can advise whether you are likely to meet the criteria and can refer you.
- Private health insurance, if you hold a policy that covers surgical treatment. Cover, excess and prior approval are covered in the next section.
- Self-funding, if neither applies or you would rather pay privately.
How private health insurance works
If you hold private health insurance, most insurers require prior approval before surgery. The practice will provide the information your insurer needs, but the application is between you and your insurer, and it is worth contacting them early.
The practice works with New Zealand's major health insurers, including Southern Cross, nib and Accuro, and with ACC for injury-related care. If you have private insurance, please check your cover, excess and any prior-approval requirement with your insurer, and talk to us about an estimate before surgery.
Things worth checking with your insurer directly:
- Whether the condition is covered, or excluded as pre-existing
- Any stand-down period on a new policy
- Your excess, and whether it applies per claim or per year
- Whether your policy pays the full surgeon, anaesthetist and hospital fees, or up to a set amount with any balance payable by you
- Whether follow-up appointments, imaging and physiotherapy are included
Self-funding
You can choose to pay for your own assessment and surgery. If you are self-funding an operation, you should receive an estimate covering the surgeon’s fee, the anaesthetist’s fee and the hospital’s costs. Those are usually billed separately by three different parties, so ask for the full picture rather than one figure.
Fees
Consultation and surgery fees are provided when you book, and you will receive a written estimate, known as informed financial consent, before any surgery, so you know what you are committing to before you decide. Injury-related care may be covered by ACC.
Questions about costs
If you are unsure which pathway applies to you, phone the rooms on 027 555 5210 before your appointment. It is a reasonable question and it is better asked early.
This page describes how funding generally works in New Zealand. It is not a quote, and ACC and insurer decisions are made by them, not by the practice.