[ausbokkie]

Hi all,

I'm hoping others are just as confused as I am - I just don't seem to be able to understand how PHI works!

Basically, I have Top Hospital cover with $250 excess and will be fully covered as of March (baby due June so that's ok). My hospital advised that I call my fund to check on fees we may be up for and I am just as in the dark as before.

If it's a straight, normal birth then apparently there will be no fees apart from the excess.

If I need anaesthetist, pathology etc then the fund will pay 125% of the Medicare schedule fee and we pay anything above that. They say to contact my doctor to see who he will be using and what the fees may be like - apparently they don't do no gap. I have heard that the hospital I am going to often does not charge for anaesthetists so that might be ok but I am terrified of not knowing what we are going to be up for.

Any experiences with this that might make me feel better? Panicking slightly with the unknown!

Thanks in advance.

[tiggy2]

It is confusing!
If you have a straight forward birth your hospital costs will be minimal, but you will still be up for at least a few grand from your OB for managing the pregnancy.

According to private health insurers NIB, out-of-pocket expenses for a private health pregnancy and birth is anywhere from $2,445 to $8,355 – and that’s after a Medicare rebate of between $2,022 and $2,111.

http://www.kidspot.com.au/ShoppingList/fam...657+184+article

Your Ob should give you a detailed breakdown if their costs, usually these are spread through the pregnancy with the biggest at 20 weeks - this one was $2500 for me. You get a bit back from medicare but not heaps. Unless you have access to bulk billing you will also have multiple blood test and ultrasound feed out of pocket.

Hope that helps

[tiggy2]

My actual hospital cost was about $800 out of pocket for anaethetist, paed, second Ob and excess.

[Koobie83]

I have no idea. I don't get why you pay for cover and have to pay half the costs anyway. That's why I'm going public.

[Rusky99]

It really depends on what you need on the day.

Where I went, the anaesthetist was about $1000 out of pocket if it was during standard hours. Out of hours, it was more. I ended up needing a caesarian after hours and this resulted in anaesthetist fees of around $3000. The caesarian also resulted in fees of $850 for the assisting surgeon.

If you only need gas and/or pethadine, you won't have any of these fees.

Paediatrician was around $300.

[Natttmumm]

We pay the Obyn 80 per visit and then about 2.5k after 30 weeks. Some of this is Medicare claim able it not much. pHI doesn't cover any of that.
The hospital was covered but I think there was a gap for the epidural and paediatrician.
This pregnancy we have allowed about 4 k out of pocket.
Also all the scans costs around 350 and we only got about 70 ish back. We have had two formal scans

[soontobegran]

The hospital costs are generally fully covered by your PHI but PHI does not pay doctors fees, this is where you'll be out of pocket.
Check with your Obstetricans rooms what his fee structure is and take it from there.
Good Luck.


Koobie83, people choose PHI so they have choice of caregiver and to be able to birth in a private hospital. It is important to many people.

[Dylan's Mummy]

A doctor needs to be registered with the fund as a "gap cover, known gap" or something similar for you to get more than the Medicare Benefits Schedule (MBS) fee. If your doctors don't have this type of registration then you will just get the 100% MBS and have to pay the rest. A lot of doctors have a agreement with funds to charge the amount that they have contracted with the fund so you may not have any out-of-pockets (for your in-patient fees anyway) for the obstetrician. This is one reason the "management" fee is expensive, it's how the doctors get around the set amount that the funds contract with them.

Your obstrician's receptionist really should be able to tell you what your out-of-pocket for the obstetric fee wil be, they are aware of what the Medicare rebates and health fund rebates are as well as the registration they have with each fund and the amounts the funds pay.

I find that most pathologist will just charge the MBS fee so you aren't likely to have any out of pocket expenses. With the anaeathetists you may not have a choice because I don't think they are on call the way an obstrician is. If you need an epidural in the middle of the night you probably have to use the ones who are on call that night. I had my baby at the Mater Private in Brisbane and both the public and private babies are born in the same place and they had an oncall anaesthetist and I wasn't billed at all.

If your doctor isn't registered, remember that if your total out of pocket expe ses for hosptital admissions and extras (dental, optical. Physio etc) are above a certain amount (not sure what but about $2000 and something) that you can claim a rebate at tax time. To do this you will need an "annual statement of benefits" from your fund, you will need to specifically ask them for this. You will also need a similar statement from Medicare.

For any of your outpatient consults, scans, tests etc, there is the Medicare Safety Net where once your out of pockets reach a certain amount in the calendar year ($2500 perhaps), Medicare will pay a percentage of your out of pocket expenses. Because of this, my out of pockets for the regular obstrician consults was only about $6. For the large "management" fee Medicare have a cap on what they will pay so you won't get much back for this one but if you are able to pay the management fee early next year then you may reach the safety net amount quickly and for the rest of 2013 your family will have cheap doctors visits. Contact Medicar to make sure you and your family are registered for the safety net.

This post has been edited by Dylan's Mummy: 17/12/2012, 10:08 AM

[schooldaze]

I had no idea it was so expensive! I am so grateful for the care I received through the public system - more than happy to pay a medicare levy each year.

[Dylan's Mummy]

Also, a paedatrician will visit your baby in the ward. They will bill you for this. This consultation is classified as an "outpatient" visit because your baby isn't classed as being an admitted patient. Medicare pay 80% of the medicare amount for out patient consults.

If your baby has to be admitted to the special care nursery then they will be classed as being admitted. You may need to check with the hospital on doctors fees for special care nursery doctors. Also, if you are going to a small hospital or your baby needs a lot of intensive care, it may be transferred to a larger hospital that has the facilities to care for it.

The health insurance industry runs according to the rule that the government have in place. Fuds cannot pay for outpatient expenses and for inpatient expenses they pay 25% of the medicare amount (Medicare pay 75%). Except in the case where the doctor has a "gap" type arrangement. If funds were to cover the whole amount that doctors billed their premiums would be huge and nobody would join.