If you're thinking about starting a family, a key decision is whether to use public or private maternity care.
Because private health insurance for pregnancy comes with long waiting periods and is only available on certain plans, it's important to plan ahead so you have the right cover in place and can access the services you want when you need to.
Do I need private health insurance for pregnancy?
No, private health insurance isn’t required to have a baby in Australia. Medicare covers pregnancy and birth in the public system, which is free and offers a high level of care.
As a public patient, your care is comprehensive and includes routine ultrasounds, blood tests, immunisations, pregnancy counselling, and support from both midwives and obstetricians.
Private health insurance is only needed if you want to be treated as a private patient, either in a public or private hospital. This is typically the more expensive option, as you’ll still have out-of-pocket costs even with cover, but it may be worth it if continuity of care, choice of doctor and a more personalised level of care are important to you.
What does private health insurance cover for pregnancy?
As long as you have an appropriate level of hospital cover that includes pregnancy and birth, you can generally claim in part or in full for:
- Hospital accommodation, including a private room where available
- Labour ward and theatre fees, including caesarean section
- Obstetrician and anaesthetist fees up to the Medicare Benefits Schedule (MBS) fee
- A longer hospital stay compared to the public system (typically several nights)
- Hospital-based IVF treatment
- Hospital-administered pharmaceuticals
- Postnatal support services available through the hospital
However, even with private health insurance, there are costs you will likely need to pay out of pocket:
- The gap on obstetrician fees: private health insurance covers obstetrician fees up to the MBS schedule fee, but most doctors charge above this rate. The difference is called the gap, and it can run to several thousand dollars. Some obstetricians participate in gap cover schemes with specific health funds, which can reduce or eliminate this cost , so it’s worth checking with both your obstetrician and your insurer before committing.
- Antenatal appointments and scans outside hospital: GP visits, routine ultrasounds and specialist outpatient appointments during pregnancy are generally not covered by hospital cover, though some extras policies may contribute toward outpatient specialist costs.
- Pre-discharge paediatrician check: the paediatrician visit before your baby is discharged may not be covered.
- Excess or co-payment: depending on your policy, you may still need to pay an excess or co-payment when you are admitted to hospital.
Can extras cover help with pregnancy costs?
Many higher-tier extras plans can contribute toward out-of-hospital pregnancy costs such as physiotherapy, pregnancy massage, lactation consultant fees and antenatal and postnatal classes.
Annual limits and waiting periods apply (typically two months for antenatal and postnatal care), so it’s worth checking your PDS or contacting your fund to confirm what is covered under your policy.
What level of cover do I need for pregnancy and birth?
To be covered for pregnancy and birth as a private patient, you generally need Gold hospital cover. This is the only tier that must include pregnancy and birth services as standard under Australian private health insurance rules.
Some Silver Plus policies may also include pregnancy and birth, but this varies between health funds and individual policies and not a guaranteed inclusion.
Lower tier policies (Basic, Bronze and standard Silver) do not include obstetric services. If you hold one of these plans and are planning a pregnancy, you will need to upgrade to an eligible Gold or Silver Plus policy and then serve a 12-month waiting period before you can claim pregnancy-related hospital benefits.
Understanding the 12-month waiting period
However, if you are already pregnant without cover in place, it is too late to serve the waiting period before giving birth, meaning this pregnancy cannot be covered under private health insurance.
If you are switching from one health fund to another, your waiting period does not reset. You will only need to serve any remaining portion of the waiting period with your new fund.
Is my newborn covered under my policy?
If your baby doesn’t need additional medical care after birth, they usually won’t be admitted as a separate patient during your hospital stay. In this case, their routine care is generally included as part of your admission.
However, if your baby needs care in a special care nursery or neonatal intensive care unit (NICU), they may be admitted as a separate patient.
While all medically necessary care will still be provided regardless of your insurance status, where your baby is treated can affect how their treatment costs are covered.
If they’re treated in a public hospital, their care is generally covered under Medicare. If treatment takes place in a private hospital, the admission is typically billed separately. To have private cover apply in this situation, your baby will need to be added to your policy.
If you currently hold a singles or couples policy, you will need to upgrade to a single parent or family policy to cover your newborn.
Most funds allow you to backdate your baby’s cover to their date of birth, provided you notify them within a set timeframe, typically 60 to 90 days. Your baby will usually inherit any waiting periods you’ve already served, meaning they won’t need to start them again. However, if you notify your fund after this window, cover will generally only apply from the date you contact them, and standard waiting periods may apply.
How much does pregnancy health insurance cost?
Private maternity cover is not cheap. Pregnancy and birth services are only included on Gold and some Silver Plus policies, which are the highest tier of hospital cover and the most expensive on the market.
Gold-level cover typically costs hundreds of dollars per month. Based on current pricing from major health funds, a singles policy can range from around $270 to over $400 per month, depending on your age, location, excess and the insurer you choose.
Silver Plus policies are usually cheaper, but not all include pregnancy and birth, so it’s important to check the policy details carefully before relying on them.
On top of your premium, you should also expect significant out-of-pocket costs. Private obstetricians set their own fees, which often exceed the Medicare Benefits Schedule rate, leaving a gap that insurance does not cover. Other costs such as anaesthetist fees, specialist appointments and the hospital excess or co-payment will also add up. For many families, out-of-pocket costs for a private birth run to several thousand dollars even with comprehensive cover.
How to compare pregnancy health insurance policies
-
Make sure pregnancy and birth is included
Gold policies must include obstetrics as standard, but other policies don’t. If you hold a lower tier policy, you’ll need to factor in the time and cost of upgrading.
-
Look at premiums
While hospital policies must offer the same inclusions within each tier, premiums for Gold cover can vary significantly between funds. It is worth comparing prices across a range of policies to make sure you are getting value for money.
-
Review excess and co-payments
Knowing you will be using your cover, think carefully about the trade-off between a higher excess with lower premiums or a lower excess with higher premiums. Also check whether a co-payment applies, as this can add to your costs.
-
Check gap cover arrangements
Look for a policy with gap cover agreements with obstetricians in your area, which can significantly reduce your out-of-pocket costs at the time of birth.
-
Consider the cost and timing of adding your baby
Check how much it will cost to upgrade to a family or single parent policy and when you need to make the change to ensure your newborn is covered.
-
Explore other policy benefits
Consider other benefits a policy may offer, such as extras inclusions and any postnatal support programs that may be useful after the birth.
