Private health insurance and pregnancy

What is private health insurance?

Private health insurance helps cover the costs of treatment in hospital as a private patient. It can also cover some other treatments that Medicare doesn't cover.

If you elect to be treated as private patient, you can choose your obstetrician, midwife and the hospital that you would like to give birth in.

Private health insurance may be used to fully or partially cover:

• your hospital stay in a private hospital
• out-of-pocket fees for private doctors or midwives
• some antenatal tests that aren’t covered by Medicare

You do not have to be covered by private health insurance in Australia. All Australian residents can access free healthcare through Medicare.

However, the Australian Government provides a rebate to eligible people to help cover the cost of private health insurance premiums.

When might I buy a health insurance policy?

It’s a good idea to consider your pregnancy care preferences while planning a pregnancy. Most private health insurance policies have a 12-month waiting period. During this time, you can’t claim any pregnancy-related health expenses.

If you want private obstetric care during your pregnancy and birth, you will need to do one of the following:

• Buy a private health insurance policy with relevant cover at least 12 months before you become pregnant.
• Upgrade your existing policy 12 months before you become pregnant.
• Pay for private care yourself.

What should I look for in a health insurance policy for pregnancy and birth?

It's a good idea to check with the hospital, your doctor and/or midwife before taking out private health insurance. Make sure you have the cover you need and understand any extra costs that you may need to pay.

Check the health insurance policy carefully, as some don’t cover obstetrics or midwifery. Alternatively, they may only pay restricted benefits. For example, they may only cover you as a private patient in a public hospital.

Will my policy cover my newborn baby?

It’s important that your baby is covered from birth in case they need immediate hospital treatment or other medical care.

Every fund has different policies about covering newborn babies. It’s important to check with your fund about their rules for covering newborn babies. You should ask if your baby will automatically be covered after the birth under your own policy, or if you will need to change to a family policy.

Many funds will ask you to upgrade your policy to a family policy 1 to 3 months before your baby is born. Some funds may ask you to upgrade up to 12 months before, so any possible congenital conditions are covered. Check with your fund to make sure that any waiting periods for this upgrade will cover your newborn.

What if my baby is unwell or premature?

If your baby is healthy when you give birth, they will not usually formally be admitted to the hospital.

Babies who are born premature or are very unwell may need care in a Neonatal Intensive Care Unit (NICU) in a large public hospital.

• If you’re a public patient in a public hospital, most costs are covered by Medicare.
• If you’re a private patient and have a premature baby, your fund may cover the costs, depending on your policy.
• If you have a baby within your private health insurer’s waiting period, your baby may not be covered for costs. This is another reason to consider your level of private health cover ahead of time, if possible.

Your baby will be charged separately for their nursery care, in addition to the charges for your hospital stay. Check with your health fund to see what your baby is covered for.

What if I am having twins or triplets or more?

A multiple pregnancy can increase your costs significantly. Check with your hospital about the costs to expect with multiple births, and check with your private health fund to see what costs are covered.

If you’re expecting twins, triplets or more, there’s a higher chance they might be born prematurely and will need to be admitted to hospital. Some multiple births involve care in the NICU for days or weeks, which can be very expensive.

What are out-of-pocket costs?

Some costs are not covered by private health insurance. These may include:

• medical services that are provided outside of the hospital
• specialist consultations and check-ups with your obstetrician
• a portion of the hospital fees
• paediatrician pre-release check-up and visits

Some of these costs may be claimed back from Medicare.

Depending on your policy, your private health fund may charge an excess or co-payment for your or your baby’s admission to hospital.

For more information about out-of-pocket costs, you can check with your health provider, your insurer and the hospital staff. You can also visit the Commonwealth Ombudsman for a fact sheet on obstetrics and pregnancy.

What happens if I’m pregnant, but I’m not covered by my private health insurance policy?

If you’re not covered by private health insurance and you want to be treated in a private hospital, you will have high out-of-pocket costs. You will be able to claim part of the costs for a private obstetrician or eligible midwife from Medicare, but you will need to pay the hospital costs.

Remember that everyone with a Medicare number is eligible to receive high-quality care in a public hospital or birthing centre that is fully covered by Medicare.

To find out more about the expected costs surrounding your pregnancy, visit the Medical Costs Finder.

What financial assistance can I get to help with the costs of my pregnancy?

If you are experiencing financial difficulty and need help with the costs surrounding having a baby, visit the Medicare services for conceiving, pregnancy and birth page to learn about other forms of assistance you may be able to apply for.

You may want to register for the Medicare Safety Net. If you spend above a certain amount on healthcare in a calendar year, you can get more money back from Medicare.

Resources and support

You can contact the Private Health Insurance Ombudsman for information about private health insurance and to compare health insurance policies on 1300 737 299. They also provide information:

• to help you plan for private hospital cover
• about the Australian Government Private Health Insurance Rebate

The Royal Women’s Hospital outlines many of the costs of pregnancy care and having a baby.