Understanding Pregnancy in health insurance

Starting your own family is an exciting adventure, although it’s not one without the unknown. Because of this, many of us prefer the comfort of a private hospital room and our own doctor when it comes time to giving birth.

However, with growing expenses (cue thousands of nappies – and then some), many also wonder if they really need to take out private health insurance for their pregnancy. To help you make the most informed decision for your needs, we’ve broken down important factors regarding how pregnancy is covered in private health insurance.

Is health insurance for pregnancy worth it?

Both public and private hospitals in Australia provide quality care for mothers during their pregnancy and the birth of their child. When it comes to private health insurance, however, you are able to choose the obstetrician who looks after you during both your pregnancy and delivery, provided your hospital cover includes pregnancy and birth-related services (otherwise known as obstetrics cover).

Once you’ve served your 12 month waiting period, you’ll be covered for accommodation, labour ward costs, and doctors’ fees at an ‘agreement private hospital’ of your choice. Depending on your health fund, you may even be able to cover the costs of your pre-natal classes.

With obstetrics cover (again, provided you have served your waiting period), you will also be paid a benefit towards your obstetrician’s fees during delivery (ask early on for a breakdown of the costs from your doctor and insurer). However, any consultations prior to being admitted to hospital will not be covered by your health fund, so set aside some money for those expenses. That being said, you can claim some portion of these costs back through Medicare.

Obstetrics cover: what you should consider

While private health insurance covers some of your medical fees, there are some pregnancy-associated costs that may come out of your pocket. It’s therefore important you carefully check the Product Disclosure Statement (PDS) of your health insurance policy to see what is and isn’t included as part of your cover. Some policies will not cover obstetrics, or may only pay restricted benefits; some may also only cover you if you’re a private patient in a public hospital – this means if you want to deliver your baby in a private hospital, you’ll need to make sure coverage as a private patient in a private hospital is included in your policy.

Some things you will be expected to pay out of your own pocket for can include:

• The ‘gap’ on medical services while admitted to hospital; your health fund and Medicare cover the equivalent of the Medicare Benefits Schedule fee, while the remainder is out-of-pocket. Some health funds and certain doctors/specialists have gap cover agreements where the fund may cover some or all of the fees for your hospital treatment. If your doctor doesn’t have this agreement, you’ll likely pay out-of-pocket for their fees.

• When it comes to your newborn’s check-up before you go home, you will be required to pay for the attending paediatrician. As with most cases (except complicated births), your baby will not be admitted as an in-patient at the hospital, so this fee can’t be claimed on your health insurance policy. It can, however, be claimed on Medicare and a gap is usually paid out-of-pocket.

• In cases where your baby needs immediate hospital care (i.e. born prematurely), you could be out-of-pocket for admission to the Special Care Nursery or Intensive Care Unit if they are not covered by the health insurance policy.

• Out-of-hospital medical services, like obstetrician’s check-ups and specialist consultations; a portion of these can only be claimed on Medicare.

• Excess or co-payment for hospital admissions is required by some policies.

Assisted Reproduction Services and IVF

Private health funds can cover Assisted Reproductive Services (ARS) to treat infertility, including In Vitro Fertilisation (IVF) treatment and Gamete Intra Fallopian Transfer (GIFT). It’s important to be aware that these procedures have a 12 month waiting period and aren’t always automatically included in policies that cover natural birth and obstetrics.

As only in-patient services, like your hospital admission, are covered under private health insurance, you may be out-of-pocket for certain costs associated with ARS procedures. Certain out-of-hospital procedures that won’t be covered by your insurance, but may be claimed through Medicare, include:

• blood tests
• ultrasounds
• scans
• diagnostic and pathology services.

Be sure your hospital advises you before your admission of any procedure costs and charges.

When it comes to IVF, egg collection is considered the main procedure, which is carried out in an operating theatre as an in-patient. These theatre fees and your accommodation are both covered by your health fund, and you will also be paid a benefit towards anaesthetist and doctors’ fees. You may need to pay the ‘gap’ fee for medical costs that go above the Medicare Benefits Schedule fee.

More on waiting periods for obstetrics cover and IVF

Private health insurance should be taken out as early as possible, as everyone is required to sit through a 12 month waiting period for two key services before making claims:

1. Obstetrics, i.e. services related to childbirth.
2. Assisted reproduction services, like IVF.

Even if you deliver prematurely, some policies will not provide cover unless you have completed your 12 month waiting period.

Extras cover for pregnancy

Extras cover can be especially helpful during pregnancy, and can be chosen in conjunction with a hospital insurance policy. Depending on your health provider, some extras policies include antenatal care, which educate and provide advice to pregnant women and their partners before their baby arrives. Postnatal classes are also valuable for new mothers. With these extras, you might be able to claim on birthing and breastfeeding classes, midwife visits pre or postnatal, and sleep settling consultations.

Physiotherapy is also a helpful service available in extras cover that can help women who have suffered from pregnancy complications, as well as provide exercises that can help ease back pain, pelvic pain, and urinary incontinence.

Claiming on out-of-pocket psychology appointments can be helpful as well, especially since many women – about one in seven in Australia each year – can develop Postnatal Depression. Having a child is a wonderful experience, but it is a life-changing adjustment. As such, it can be a great idea to organise a safety net where you can receive advice and guidance from a professional.

Waiting periods for extras cover varies between individual health funds.