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Understanding what Medicare and Private Health Insurance covers
Inpatient vs outpatient
When it comes to planning your hospital procedure, there are two terms that you’ll hear often – ‘inpatient’ and ‘outpatient’. Knowing the difference between the two will help you understand if you’ll be covered by Medicare, your private health insurance, or whether you’ll need to pay for some of the treatment yourself.
An inpatient is when you’ve been formally admitted to a hospital for overnight surgery (like if you need a knee replacement) or day surgery (such as arthroscopies or endoscopies).
You can also be classified as an inpatient if you’re admitted to a registered day clinic by a doctor, and receiving short term medical treatment, like cataract removal, colonoscopies and skin cancer removals.
There are two ways you can be admitted as an inpatient: through an emergency situation or a pre-booked surgery, or treatment by a doctor.
What happens when you visit the emergency department?
You will only be classified as an inpatient if you have been formally admitted to the hospital for medical treatment following your visit to the emergency department.
In private hospitals, an emergency facility fee is charged which is not covered by Medicare, and therefore not private health insurance, regardless of whether you’re admitted for further medical treatment in that hospital. Some hospitals may choose to waive this fee at their discretion.
You’ll be classified as an outpatient if your treatment is provided in a doctor’s surgery, specialist’s clinic, or emergency department (when you haven’t been admitted to hospital).
By law, private health insurers aren’t allowed to cover outpatients consultations or treatments, these include:
- Consultations with your GP or specialist before and after your surgery
- Diagnostic and pathology tests, like scans, blood tests, injections etc.
- Type C procedures (procedures conducted in a specialists rooms, like skin lesion/mole removal)
If you’re an outpatient, your costs will mainly be covered by Medicare, but if you’re not bulk-billed, you’ll most likely have some out-of-pocket-costs.
What Hospital cover will pay for
If included in your policy, when you’re admitted to hospital, you’ll be 100% covered for:
• Your hospital accommodation (including registered day facilities)
• Your theatre, nursing care, labour ward and intensive care fees
• All admission related PBS prescriptions relating to your admission, while you’re in hospital
• An extensive range of Government-recognised surgically implanted prostheses
Depending on your level of Hospital cover, it will also pay towards:
• Inpatient medical fees (e.g. blood tests, scans & recovery equipment
• Medicare Benefits Schedule (MBS) fees charged by your specialist
The information contained here is of a general nature and does not take into account your personal medical situation. The information is not a substitute for independent professional medical advice and is not intended to diagnose, treat, cure or prevent any disease or used for therapeutic purposes. Should you require specific medical information, please seek advice from your healthcare practitioner. Health Partners does not accept any liability for any injury, loss or damage incurred by use of or reliance on the information provided.