Hospital cover

What’s important to you? Having your baby in a private hospital? Being able to choose your obstetrician? Accessing pregnancy support through your cover? These considerations will help you assess the cover options below.  

While it won’t be relevant for everyone, we’ve included info on Assisted reproductive services too.

Top Hospital (Gold)

For maximum baby-related cover, go for gold: Top Hospital (Gold)!

You can claim for

Pregnancy and birth:

• Obstetrician and any other specialist doctors – for in-hospital (inpatient) care. See Doctors
• Private hospital – accommodation, delivery suite, operating theatre and more. See Hospitals
• Public hospital as a private patient. See Hospitals

Assisted reproductive services*:

• Specialist doctor(s) – for any in-hospital (inpatient) care. See Doctors
• Private hospital – for inpatient procedures only. See Hospitals

Mid Hospital (Basic Plus) & Basic Hospital (Basic Plus)

These options can work for people who want to claim towards specialist doctor fees but are happy to have their baby at a public hospital (as a private patient).

That’s because Mid Hospital (Basic Plus) & Basic Hospital (Basic Plus) provide 'restricted' cover for these services. Here's what that means:

You can claim for

Pregnancy & birth:

• Obstetrician and any other specialist doctors – for in-hospital (inpatient) care. See Doctors
• Public hospital – accommodation (shared room), delivery suite, operating theatre and more. See Hospitals

Assisted reproductive services*:

• Specialist doctor(s) – for any in-hospital (inpatient) care. See Doctors

You can't claim for

For restricted services, you can’t claim more than the current government fee for a shared room (at public or private hospitals).

Here’s how it works:

• Public hospital – a public hospital is far more likely to charge the government fee for a shared room, but you still need to ask if your chosen hospital charges private patients more than that, because you’ll pay the difference.

• Private hospital – again, you pay the difference between the government fee for a shared room and what the hospital charges. In a private hospital, this could be a lot more.
  
  Plus, you pay for any operating theatre, intensive care or neonatal intensive care costs, because they’re not included in the accommodation fee (which they are at public hospitals).

Mid Classic (Silver Plus) & StarterPak (Basic Plus)

Mid Classic (Silver Plus) and StarterPak (Basic Plus) don’t provide cover for Pregnancy and Birth or Assisted Reproductive Services in a private or public hospital.

So if you’re on one of these – and want to have your baby through the private system – switch to one of the options above before you start trying for a baby.

That’s because there’s a waiting period of 9 months before you can claim for Pregnancy and Birth and 2 months for Assisted Reproductive Services (12 months in the case of pre-existing conditions^).

If you fall pregnant before switching your cover, the public system may be a better option.

What you can’t claim for on any level of cover

It’s equally important to know what isn’t included on Hospital cover, whichever option you go for. This includes:

Outpatient services

Hospital insurance can only cover inpatient hospital services. This is treatment you get when you’ve been admitted to hospital.

You can’t claim for outpatient services like:

• Obstetrician appointments
• Scans, pathology and other tests
• Newborn checks or treatment (because newborns are usually treated as outpatients).
  See more on newborns in hospital

This inpatient rule applies to all health funds – as the Department of Health explains in costs for services outside hospital.

Non-medical costs

You won’t be able to claim for non-medical costs either, such as:

• Obstetrician’s pregnancy management fee
• Deluxe birth suite upgrade
• Hospital admin fees.

*Many of these are likely to be outpatient services, which you can’t claim for on Hospital cover. Your specialist will be able to explain what’s relevant to you. You may want to check Medicare’s info on assisted reproductive services and IVF too.

^A pre-existing condition is an illness, ailment or condition where the signs or symptoms of which, in the opinion of a medical practitioner appointed by Nurses & Midwives Health, existed at any time during the 6 months before getting Hospital cover or transferring to a higher level of cover. This rule applies to new members and existing members who are upgrading their level of cover. If you’re new to private health insurance, you’ll have to wait 12 months before you can receive benefits for items or services related to a pre-existing condition. If you change to a higher level of cover, you may have to wait 12 months to receive benefits, including those for services not previously covered. A 12-month waiting period applies to all pre-existing conditions except pregnancy & birth-related services (which is 9 months) and psychiatric, palliative care and rehabilitation (which are 2 months).