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Private hospital insurance maternity checklist

05 December 2022

Planning for a baby is an exciting time, and with a little pre-planning you can make sure you are able to choose the hospital and obstetrician where you want to give birth by taking out private hospital insurance with maternity cover.

Our General Manager of Health Funding, Strategy and Performance Peter Kahn shares our checklist of questions to ask your health fund.

Planning a baby

Planning for a baby should include whether you want to purchase health insurance including maternity cover.

It’s an important decision and it needs to be made at least 12 months before your baby is due. By planning ahead and taking out private hospital insurance as early as possible, you will have served any waiting period and need not worry.

If you wait until you conceive before upgrading your insurance, you may find that you will not be fully covered and have significant out of pockets payable if you choose maternity care in a private hospital. 

You are still able to receive care at one of our private hospitals, as a self-funded patient or if your private health insurance does not cover maternity care. You will likely have a number of out-of-pocket costs, so it is best to call the hospital direct to find out what to expect.

So what to ask your private health fund?

Are maternity/obstetric services covered in a private hospital on my policy?

This is a very important question to ask as you need to ensure your fund covers you and your baby’s care in a private hospital.

The Australian health insurance classifications mean your cover will need to be a Gold or Silver Plus product. This will cover everything necessary so you can have your baby in a private hospital.

If you have an existing health insurance policy, ask if you can add pregnancy and birth coverage.

If your fund asks you for an ‘item number’ (Medicare number), you can quote 16519 or 16520.

Have I served waiting periods for pregnancy and birth?

You may find that you and your baby are already covered under your existing health insurance policy and that you have served all waiting periods on your policy, this is usually 12 months.

If you have upgraded your policy recently, it is really important that you understand your waiting periods, it is best to confirm with your health fund how long your waiting period is. 

If your waiting periods have not been served, you will have significant out of pocket expenses to pay for your admission.

Am I on a single, couples, single-parent or family cover?

Your health fund may require you to upgrade your cover to include your baby. If you are on a single/couples policy, make sure to ask when it may be time to consider upgrading to family or single parent policy to ensure your baby is covered as well as you.

Will I have an excess or co-payment to pay for my pregnancy/birth admission?

The hospital will inform you of expected out of pocket costs for your admission but it is important that you confirm with your health fund if you have an excess and/or co-payment on your policy.

If my baby is admitted to a special care nursery for medical care at birth, will I be charged an excess or co-payments apply for my baby to be admitted to hospital?

Each health fund has different rules about whether there will be an out of pocket cost for a baby admitted to hospital. This will also depend on the type of cover and policy you hold with your health fund, so it is best to confirm with your fund.

Other helpful tips

Change of name

Another very important factor as a privately insured maternity patient to consider is ensuring that your name in consistent in three places:

  • on your Medicare Card
  • on your health fund insurance policy
  • on your hospital record.

If you have recently married or have changed your surname, check that your name is listed the same way in all three places as this will ease the claiming process.

Choosing a private obstetrician

One of the benefits of choosing to be a private patient, is that you are cared for by one of our obstetricians who is accredited to work at our hospitals. You can choose an obstetrician by browsing our Find a Specialist search and asking your GP for a referral.

Final considerations

Medicare provides a rebate for common outpatient tests such as an ultrasound or blood tests.

Your hospital insurance policy only pays for services provided while you’re an inpatient admitted to hospital. 

You can claim any medical services, such as doctor visits from Medicare. 

You should ask your specialist for a list of fees so you understand what you can expect to pay out-of-pocket and what Medicare rebate you may receive.

You may have other out-of-pocket expenses relating to your anaesthetist or paediatrician as well as for medication issued on discharge from hospital. Speak to your obstetrician about any likely charges.

St John of God Health Care
Peter Kahn - Group Health Fund Manager
Peter Khan is the Group Health Fund Manager at St John of God Health Care.