Health insurance and maternity cover in Australia: the 12-month rule

Medicare first, insurance second

Before the insurance question, the baseline. In Australia the costs of pregnancy care in a public hospital or birth centre are mostly covered by Medicare, which covers Australian citizens and some visitors. Pregnancy, Birth and Baby states directly that if you have a Medicare card, this can cover the costs of giving birth in a public hospital, and that if you give birth at a birthing centre attached to a public hospital, Medicare will cover the costs of your birth, with possible out-of-pocket costs for some tests.

So private health insurance in Australia is not the thing that makes maternity care possible. It is the thing that buys you a chosen obstetrician, a private hospital or a private room. That is a real benefit, but it is a preference purchase, and it comes with a timing rule that is unforgiving.

The 12-month waiting period, set by government

The Australian Government sets the maximum waiting periods insurers can impose for hospital treatment. They are:

12 months for pre-existing conditions. 12 months for pregnancy and birth (obstetrics). Two months for psychiatric treatment, rehabilitation or palliative care, even for a pre-existing condition. Two months in all other circumstances.

Read the obstetrics line with a calendar in your hand. A 12-month wait means cover has to be in place roughly three months before you conceive to be useful for the birth of this pregnancy. Joining after a positive test does not work for this baby.

The entitlement rests with the mother

The Private Health Insurance Ombudsman makes a point that is easy to get wrong on a family policy: the entitlement to pregnancy benefits rests with the mother. She needs to have served the full waiting period before being admitted to hospital in order to claim benefits. Being on a partner's long-standing policy does not automatically transfer their served time to you if you were added recently.

The cheap policy problem

This is the most expensive misunderstanding in Australian private cover. Many less expensive hospital policies do not include obstetrics at all, or pay restricted benefits that cover you for obstetrics only as a private patient in a public hospital, not in a private hospital.

Restricted benefits are not the same as no cover, and they are not the same as full cover. If your plan is a private hospital birth with a chosen obstetrician, check the clinical category on your Private Health Information Statement and confirm in writing that obstetrics is covered at the level you expect.

Getting your newborn covered

A single membership does not cover a baby. If you have a single membership, or you are a dependant on a family policy and are expecting a child, you need to transfer to a family membership or a single parent membership for your newborn to be covered.

The timing matters here too. If you want your child insured from the moment of birth without waiting periods, you may have to transfer to the new policy several months before your child is born. Do not leave this until the third trimester.

Out-of-pocket costs are separate from all of this

Even with full obstetric cover, Medicare and your fund cover some of a private hospital stay and you may still pay extra fees known as out-of-pocket costs. Pregnancy, Birth and Baby's advice is blunt and worth taking: ask your doctor, obstetrician or midwife what out-of-pocket fees are expected. Ask before you book. Obstetric management fees are set by individual practitioners, are not published in any government schedule, and we are not going to invent a typical figure.

If you do not have insurance

You can pay for private care out of your own pocket, or use the public system, which is what most Australians do. Public hospital care with Medicare gives you access to anaesthetists, neonatologists, a caesarean if needed and a special care nursery. You will not choose your obstetrician, and in a standard clinic you will not choose your midwife, but the clinical safety net is the same building.

What we cannot answer here

Individual policy terms, premium levels and which private hospitals your fund has agreements with are commercial matters that change annually. privatehealth.gov.au publishes Private Health Information Statements for every policy so you can compare like with like, and the Private Health Insurance Ombudsman handles complaints. Those two are the places to check, not a comparison advertisement.

What counts as a pre-existing condition

The definition is wider than most people assume and it is set by law. A pre-existing condition is any ailment, illness or condition that you had signs or symptoms of during the six months before you joined a hospital cover or upgraded to a higher hospital policy.

It does not matter whether you or your doctor knew what the condition was, or whether it had been diagnosed. A condition can still be classed as pre-existing even if you had not seen a doctor about it. The decision is made by a medical practitioner appointed by your insurer, who must take into account information provided by your own doctor.

Because your insurer needs time to tell you whether a condition is pre-existing, check well before you go to hospital rather than on admission.

The consumer protection you do have

Even with a pre-existing condition, a health insurer must allow you to purchase any type of cover, at the same price as any other person. Once you have served any waiting periods, you are entitled to claim. Insurers cannot price you out on health grounds, which is why the waiting period rules carry so much weight in the Australian system.