When it comes to having a baby, you should know exactly what you're covered for under health insurance, because chances are there will be some out-of-pocket payments to be made. You should know what you're expecting... when you're expecting.
The greatest benefit of having private health insurance when you're planning to start or grow your family is that you can choose the hospital you wish to go to from among your health fund's list of agreement private hospitals. Your costs, once you are admitted to hospital for delivery, are covered by your health fund, including accommodation, labour ward fees and also (in most cases) any theatre costs if they are incurred.
Your health fund will also pay your doctor's and specialist obstetrician's fees up to the Medicare Benefits Schedule (MBS). There may be a gap payable if your doctor charges more than the MBS and does not have a 'no gap' or 'known gap' agreement with your health fund, but the upside is that you have nine months to do your research and choose your doctor wisely.
A national study published in the Medical Journal of Australia in 2009 found that:
To be covered for pregnancy and birth-related services, you must first take out a policy that includes cover for those services and then complete your health funds' waiting period for them. In most cases, this is 12 months, which is the maximum allowable by law. Entitlements for obstetric benefits rest with the mother, so she must have served the full waiting period in order to claim benefits. This means you will need to take out health insurance (or upgrade to a cover that includes those services) as soon as you plan to start or add to your family.
If you wish to give birth in a private hospital, you must make sure that your level of hospital cover provides access to private hospitals. Some cheaper hospital covers only allow access to public hospitals, so check this beforehand and upgrade if necessary.
Furthermore, if you wish to give birth in a particular private hospital, you should check that that hospital has an agreement with your health fund, otherwise you will incur significant out-of-pocket costs. You can check the list of private agreement hospitals with moneytime's participating health funds here.
You may need to change your health cover status to 'family' and add your child onto your cover in order for your newborn to be insured from birth, with no waiting periods. This will cover them if they are required to be admitted into hospital in case of complications (eg. premature birth, admission to a special care nursery or intensive care unit). Most health funds require you to add your baby to your cover several months before their birth, so check with your health fund to find out their specific requirements.
Any medical services that take place before you are admitted into hospital as an in-patient are not covered. This includes specialist consultations and obstetrician's check ups. You will be able to claim some of these costs back on Medicare.
If you have an excess or co-payment option on your health insurance policy, then you will need to pay the excess when you are admitted into hospital for delivery.
In most cases, your child will not have to pay an excess because if your baby is healthy, they will not be formally admitted into hospital. The only cases where your baby will be required to pay an excess is:
Any medical services that take place in hospital are covered up to the Medicare Benefits Schedule by your health fund, and in cases where they have a 'no gap' or 'known gap' agreement with your hospital and/or doctor. Where there is a gap between what the health fund will pay and what your doctor charges, you may need to pay out-of-pocket. We strongly suggest you have a conversation with your doctor to discuss all the costs involved and request a written quote of expenses at the start of the treatment, even if it's just an estimate.
Before you and your baby can go home, a paediatrician from the hospital is required to check on his or her progress. Since most babies are not formally admitted into hospital as an in-patient, the fee for the paediatrician's visit cannot be claimed through your health fund and will come from your own pocket. This cost can be claimed on Medicare, although a gap may be payable depending on how much the paediatrician charges above the MBS.
In summary, here's the list of costs you should beware of before going to hospital:
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This information is correct as at September 2010, and is provided as a guideline only. moneytime strongly encourages you to check with your health fund to receive the most correct and up-to-date information regarding your entitlements under your specific health insurance policy.
