Hospital Cover: Health Insurance for Inpatients vs Outpatients

If you’re not familiar with the ins and outs of hospital cover, you might assume that it doesn’t matter whether you’re in hospital as an in-patient or as an out-patient. Private hospital insurance normally covers you as an inpatient only, so anything beyond that may not be covered. Read your private health insurance policy for the full details. With this in mind, it’s important to be aware of what constitutes an in-patient procedure and what doesn’t.

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Are you an in-patient or an out-patient?

You’re classed as an inpatient if you’re admitted into hospital for a same-day or overnight stay. This means you may be covered for the costs of operating theatres, intensive care and labour wards, diagnostic tests, medications included on the Pharmaceutical Benefits Scheme and allied services. However, you should spend some time on health insurance comparison to assess your options, as you’ll only be covered for the services included in your level of coverage. There will often be restrictions or exclusions on more basic levels of private hospital cover, so compare health insurance policies as well as premiums.

Medical costs (for example, from your doctor, surgeon and anaesthetic) can also be covered through private hospital cover – as a private patient, Medicare will cover 75% of the Medicare Benefits Schedule fee and your health fund may cover some or all of the remainder. If medical costs exceed the MBS fee, be prepared to pay a ‘gap’ payment, as private hospital cover may not cover all of the difference. Depending on your private health fund, emergency ambulance cover may be included.

If you’re not formally admitted to hospital for a procedure, you’re deemed to be an outpatient instead. Outpatient treatments may be delivered on hospital premises, in consultation rooms or elsewhere, such as at community health centres. For example, a consultation with an obstetrician during pregnancy will typically be an outpatient service. As an outpatient, you won’t be covered by private hospital cover.  If Medicare pays benefits for a particular service, you may be able to claim the costs of Medicare instead.

Hospital cover and unplanned hospital stays

If you’re involved in an accident, many private health funds will allow you to be covered straight away after you become a member, so it may not be quite so important to compare health insurance for hospital cover as far as this is concerned.

Hospital stays that occur because of emergency treatment may be beyond your control. If you’re suddenly taken ill, the ambulance will most likely take you to the emergency ward of the nearest public hospital. Through Medicare, you can be treated as a public patient with no costs to yourself as Medicare will cover the full fee. If you have private hospital cover and would rather use that, you’ll admitted as a private patient and you should be prepared for some out-of-pocket expenses that will need to be covered by you.

There is also the option of going to the emergency ward of a private hospital but again, you won’t be covered through private hospital cover if you’re not admitted as an in-patient. Bear in mind that private hospital cover doesn’t extend to treatment in an emergency ward, as you’re not admitted as an inpatient in this scenario. Most private health funds will not pay benefits for procedures performed as an outpatient.

It’s easy to think that hospital cover will extend to any procedure performed while you’re in hospital, but in reality, private hospital cover will only pay benefits for inpatient procedures and not for outpatient procedures in which you’ve not been formally admitted to hospital. If you’re taken to an emergency ward for treatment, you can expect to be classed as an out-patient and this won’t be covered by private hospital cover.

Compare Health Insurance for the Whole Family

When you’re looking to compare private health insurance for the whole family, it may often be the case that a Family policy may provide the best value for money. Within this, there will be things to think about when you’re looking to compare private health cover that will benefit everyone.

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How long can children remain on a family policy?

For most, Family cover will be the most cost effective type of private health insurance policy and while you’ve still got dependent children living at home, they can be kept on your private health insurance policy at no extra cost. According to the Private Health Insurance Ombudsman, a dependent child is “unmarried … under the age of 18 years,” but check with your health fund to confirm their specific criteria for what is classed as a dependent child.

Your health fund may also extend this up to the age of 25 for full-time students, provided that certain criteria are met. This will often mean that your child must be studying at a recognised educational institution or in a recognised apprenticeship or traineeship, is not married, and is not working full-time or earning over a set amount. Again, check with your health fund to find out their eligibility criteria for a student dependent.

If your child fits neither of these options, you may want to look into Extended Family Cover, which may cost more than standard Family cover.

Be selective

It’s natural to want to protect your family finances against as many potential scenarios as possible, but you may not need all of the policy extras that are available to you. By narrowing your selection down to just the optional extras that are relevant to you and your family, you may help to make your private health insurance cheaper while still making sure that you’ve got the right cover for your family.

If there are any extras that you feel may be needed further down the line but not right now, don’t forget to factor in waiting periods, especially for pre-existing conditions. Many private health funds impose waiting periods of up to 12 months for pre-existing conditions (with some exceptions, e.g. for psychiatric care), so if you only look to arrange the cover after you realise that there’s a health problem in your family, you may not be fully covered until the waiting period has been served.

Some of the optional extras that may benefit your family include:

• Dental. General dental cover covers things like dental check-ups, x-rays, fillings and extractions.
• Optical. Medicare will usually cover eye tests from approved practitioners, but to cover things like glasses and contact lenses, you’ll need optical cover.
• Orthodontic. If your children need things like braces to straighten their teeth or align their jaw, orthodontic cover may help to pay for these.
• Physiotherapy. If someone in your family has a neurological, developmental or respiratory condition which requires physiotherapy treatment, you may find this cover useful.
• Podiatry. Once your children are able to walk, they may need care for their feet. Adults may also have treatment requirements for foot health at any stage in life. Podiatry cover can help to pay for treatment costs.

Making sure that your new baby is covered

To make sure that your newborn is covered straight away, make sure that you have the relevant cover at least several months before the birth. If you don’t already have appropriate cover e.g. Family Cover or Single Parent Cover, you’ll need to switch to it before the birth.

When you’re looking to compare private health insurance for the whole family, think about the level of optional cover that your family may need. Benefits such as dental, orthodontics and optical can be important where children are concerned, but you may want to exclude cover that doesn’t seem relevant to your family. As your family grows, you’ll probably need to make some changes to your policy, but you may save money by not taking on extras that you don’t yet need, as long as you take waiting periods into account. If you’re about to start your family soon, don’t forget to make sure that you have the right cover in place before the birth, or your newborn may not be covered straight away.

Health Insurance for Pregnancy

If you’re planning to start a family in the near future, you may be wondering what your options are as far as private health insurance goes. You don’t need to compare private health insurance for pregnancy if you’re happy to go through the public health care system courtesy of Medicare, but some women prefer to take the private route. If you’re one of these, here are some tips when you’re looking to compare private health insurance for pregnancy benefits.

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Where do you want to give birth?

You can choose to be treated as either a public or private patient depending on your preferences and needs:

Public health care and pregnancy

If you’re eligible for Medicare, you can receive treatment in a public hospital at no cost but you won’t have much option for choosing which doctor or midwife will treat you. Accommodation and treatment will usually be free but you may need to pay for surgical costs and medicines (if applicable).

You can expect the birth to take place in a labour ward or birthing centre (if the hospital has one) and to be looked after by doctors and midwives during the birth. A midwife will also visit you at home once you’ve been discharged. If there are any complications during or after the birth, you’ll be treated in a post-natal ward.

Private health care and pregnancy

If you’re treated as a private patient, you can be treated in either a public or private hospital. The main benefit compared to being a public patient is the ability to choose who will treat you. If you want to be treated by an obstetrician, your GP can refer you to one or you can find out which obstetricians are authorized to deliver at your preferred hospital and pick one of these. Your health fund may have agreements in place with some specialists to minimize your costs.

Visits to your obstetrician are treated much the same as visits to your GP and you can claim on Medicare for these. During the birth, a midwife (from the hospital) will take care of you but your doctor will also be on hand throughout and will also be involved in post-natal care.

What about other expenses?

Depending on your private health insurance policy, you may be covered for some or all of your pregnancy-related expenses, but there may be a ‘gap’ regarding the obstetrician fees, which should be made clear to you early on. In some cases, there may also be a ‘gap’ between hospital costs and what is covered by your health fund. If you choose to go down the private route, be sure to confirm exactly what you’re covered for so there are no surprises. With a new baby to think about, unexpected financial expenses are the last thing you’ll want!

Not all cover options include pregnancy benefits as a matter of course, and you may need to upgrade your existing private health insurance to ensure that you are covered if you do become pregnant. Be aware that many health funds require you to have had the relevant policy for a minimum time period (up to 12 months) before you become eligible for benefits. Because of these type of restrictions, you’re best placed if you can take out or upgrade your private health insurance before you become pregnant.

Can I get private health insurance if I’m already pregnant?

As many private health funds have a 12-month waiting period for pregnancy and maternity benefits, it’s worth arranging pregnancy cover before you get pregnant to make sure that you’re definitely going to be covered at the crucial time.

When you’re looking to compare health insurance for pregnancy, don’t forget to spend some time looking at the various options. A more basic level of private health insurance may have only minor pregnancy benefits, or none at all, so you may want to think about taking out a more comprehensive level or upgrading an existing policy to ensure that you’re covered adequately for what you need. With some private health funds imposing long month waiting periods for pregnancy and maternity benefits, it’s advisable to make the effort to compare health insurance options sooner rather than later.