A guide to private health insurance cover when you’re having a baby.
Planning to start a family?
It is important to make sure you know what to expect from your private health insurance when you’re planning to start a family. This information guide will help to answer the common questions that you may have.
Should I go public or private?
Health care costs can vary depending on whether you choose to be a public patient in a public hospital or a private patient in either a public or private hospital. This decision can only be made by you in consultation with your practitioner. Your choice will depend on what options are available to you and whether or not you wish to have a private Obstetrician.
For example, in some locations you may not have a choice between a public or private hospital, as there may only be one local hospital in your area. However, you may wish to elect to be treated as a private patient in a public hospital so that you can choose which Obstetrician treats you and so you can have access to a private room if one is available.
Or your choice may be guided by which hospital your private Obstetrician can treat you in, or by the services offered by your local private hospital. So it’s worth understanding what you will be covered for and what, if any, out of pocket costs you may have.
Am I eligible for cover and will my baby be covered?
Pregnancy and birth related services are covered in both a public and private hospital on all St.LukesHealth private hospital products, after a 12 month waiting period has been served. IVF and assisted reproductive services also have a 24 month benefit limitation period (see over for more information on IVF services).
If you have been covered by a family hospital policy for more than 12 months, then you and your baby will be covered, providing your baby is added onto to your policy within 2 months.
If you have been covered by a single hospital policy for more than 12 months, then you will be covered but your baby will not. To cover your baby from birth, you should upgrade your cover to a family policy from the baby’s date of birth. This should be done within 2 months of your baby’s birth date. St.LukesHealth does not apply waiting periods to new born babies if added within this 2 month period.
If you are not currently insured and are already pregnant, unfortunately you will not be covered for any treatment related to your pregnancy. You should take out an appropriate Private Hospital product at least 3 months before you are pregnant so that you have served the 12 month waiting period prior to being admitted for the delivery.
If you are covered on Public Hospital Cover (Plan code A) you only have limited cover and you should contact St.LukesHealth to discuss your entitlements.
What is covered prior to my hospital admission?
Most medical expenses that arise prior to your hospital admission are claimable through Medicare rather than your Private Health Insurance. Medicare will reimburse 100% of the Medicare Benefits Schedule (MBS) fee for GP services and 85% of the MBS fee for specialist services and all other medical treatments such as ultrasounds and blood tests. If your doctor direct bills (bulk bills) Medicare, you will have nothing to pay. The Medicare Safety Net may also help to minimise any out-of-pocket expenses you may have for medical services provided prior to your delivery. You should contact Medicare for more information on the Medicare Safety Net.
What is covered once I am admitted to hospital?
Once you are admitted to hospital, St.LukesHealth will cover the cost of your admission in a Public or Private Hospital, less any excess that applies to your policy, providing you have served your 12 month waiting period.
Between St.LukesHealth and Medicare you will be covered up to the MBS Fee for any medical services related to your hospitalisation, such as your obstetrician, anaesthetist, or assisting mid wives etc. If any of the medical charges are higher than the MBS Fee, then you may have an out-of-pocket cost for these services. However, if your doctor charges you under the St.Lukes Gap Cover Scheme, your out-of-pocket costs will be reduced or eliminated.
You should discuss with your specialists if they will be charging you under the St.Lukes Gap Cover Scheme.
What charges will apply to my baby?
If your baby is healthy, he or she won’t need to be formally admitted to hospital, meaning there will be no fees raised for the baby’s stay in hospital.
However, if your baby does need special treatment they will most likely be admitted in their own right. This means fees will also be raised for your baby. If you have taken the required steps to cover your baby under your policy, St.LukesHealth will cover the costs of your baby’s hospital admission (less any excess that may apply to child dependants on your policy). On most products however, the excess doesn’t apply to child dependants. (please contact St.LukesHealth to check the level of cover on your product)
If you are expecting twins (or any multiple births) at least one baby will be formally admitted to the hospital, even if they are both healthy. If your policy has no excess on child dependants, then you will not be charged an excess for the baby's admission, however fees will be raised for their time in hospital.
What will I have to pay for?
Medical services that occur outside of hospital including specialist consultations and obstetrician’s check-ups. These costs, like your visits to your GP, can only be claimed through Medicare.
The ‘Gap’ on Medical services incurred while admitted to hospital. You are covered up to the MBS Fee for these medical services however you may have to pay any charges above the MBS fee if your doctor does not participate in the St.Lukes Gap Cover Scheme. You should discuss any out-of-pocket costs that might occur with your doctors, and ask them if they have a ’no gap’ or ’known gap’ arrangement with St.LukesHealth. This may significantly reduce your out-of-pocket costs.
Your baby’s pre-release check-up. Before you and your baby can go home, in some cases a paediatrician will check on his or her progress. Unless your baby has been formally admitted to hospital in their own right, the fee for the paediatrician’s visit cannot be claimed on your private health insurance policy. This cost can only be claimed through Medicare and usually a gap is payable, depending on how much the paediatrician charges above the MBS Fee.
Any excess that applies to your policy. Before being admitted to hospital you should contact St.LukesHealth to discuss your level of excess and how it applies.
Tips to help you avoid out-of-pocket costs
Ask your specialist if they have a ‘no gap’ or ‘known gap’ arrangement with St.LukesHealth and if they can provide you with a written quote outlining any expected out-of-pocket costs.
Confirm with St.LukesHealth that the private hospital you have chosen is contracted with the fund.
Contact Medicare to discuss the Medicare Safety Net and how it may assist you with any out-of-pocket costs you may have on services provided out of hospital.
What if I am trying IVF or other assisted reproductive services?
I’ve held hospital cover with St.LukesHealth since before 1st April 2010 or I joined St.LukesHealth after 1st April 2010 and transferred from another fund which covered the above services:
The in-hospital costs associated with IVF and other assisted reproductive services will be covered by St.LukesHealth less any excess that applies to your policy, providing you have served the 12 month pre-existing waiting period. You should check with your doctor and IVF Clinic for a written quote for any costs that will not be part of your hospital admission. Services that aren’t part of your hospital admission, including consultations and tests, may be claimable through Medicare.
I joined St.LukesHealth after 1st April 2010 and did not transfer from another fund or I transferred from a fund that excluded the above services:
Effective from 1st April 2010, a 24 month benefit limitation period applies to the above services inclusive of the 12 month pre-existing waiting period. This means you will not be covered for the first 12 months and will only receive minimum benefits for this treatment during your second year of membership. You will therefore have large out-of-pocket costs if you receive IVF or similar treatment in your first two years of membership.
Premature Births and Complications
Premature births or complications arising from a pregnancy where a medical practitioner confirms your baby’s expected date of birth is after the 12 month waiting period will be covered, subject to any excess that applies to your policy.
Pre-natal classes and post-natal services
If you hold extras cover with St.LukesHealth you may be able to claim a benefit for pre-natal classes. The classes must be provided by a physiotherapist in private practice who is registered with this fund. To find out if you are eligible for these benefits contact St.LukesHealth on 1300 651 988.
Post natal services such as home nursing consultations and lactation support visits may also be claimable if you hold extras cover with St.LukesHealth. The provider must be a registered nurse in private practice and registered with this fund. To find out if you are eligible for these benefits contact St.LukesHealth.
Private Health Insurance Ombudsman Obstretrics Guide
Private Health Insurance Guide