Inpatient and outpatient services

If you ever need to visit a hospital, you'll either be classified as an inpatient or an outpatient. What you are admitted as will depend on whether your services will be covered under Medicare or private health insurance.

Put simply, if you're receiving inpatient care, private health insurance hospital cover will cover this. If you are receiving outpatient care, you'll need to rely on Medicare.

What is outpatient care?

Outpatient care is when you receive medical treatment without being formally admitted to hospital.

Outpatient clinics are usually located in public hospitals, doctor's consulting rooms or community health centres. They include a range of procedures, including emergency department treatment of injuries, mental health services and x-rays. Procedures and services classed as outpatient care include:

• Emergency ward treatment when you haven't been formally admitted
• GP visits
• Consultations with specialists
• Antenatal consultations with an obstetrician
• Diagnostic services such as pathology, x-rays, ultrasounds and other organ imaging
• Drug and alcohol services, including group sessions
• District and community nursing services
• Mental health services
• Dispensing medication
• Dialysis

What is inpatient care?

Inpatient care is when you're formally admitted to hospital for treatment. Generally, this is when you're pre-booked in for surgery or you visit the emergency room in critical condition. It can include overnight or day admissions.

Inpatient care tends to cover a range of more serious services and procedures, such as:

• Emergency room patients who are admitted to hospital
• Intensive care
• Surgical treatment for a wide range of injuries or conditions, for example heart surgery, joint reconstructions and appendix removal
• Some cancer treatments
• In-hospital pharmaceuticals

Does private health insurance cover outpatient services?

No. When you receive treatment as an outpatient, in most cases you won't be covered by private health insurance.

You will instead need to rely on cover from Medicare, which provides benefits for things like GP visits, specialists' consultation fees, X-rays and pathology, and eye tests performed by optometrists.

Medicare covers 85% of the Medicare Benefits Schedule (MBS) fee for visits to the doctor that occur outside of hospital, but if you visit a doctor who bulk-bills then you may not have to pay anything.

Private health insurance can help out with other out of hospital services though if you get extras cover. This can include:

• Dental exams and treatment
• Glasses and contact lenses
• Physiotherapy and chiropractic treatment
• Speech and occupational therapy
• Hearing aids
• Natural therapies, for example acupuncture or naturopathy

Why can't private health insurance cover outpatient services?

In Australia, Medicare is designed to handle most outpatient or non-hospital care, like GP visits, specialists, blood tests, X-rays and other services provided outside of a hospital setting.

Private health insurance was introduced to complement, not duplicate, Medicare. So insurers focus on hospital and extras (dental, physio or optical) rather than routine outpatient care that Medicare already subsidises.

By law, private health insurance funds can't cover services that are already subsidised by Medicare when provided outside a hospital. This is part of the Private Health Insurance Act 2007, which prevents insurers from paying benefits for services that attract a Medicare benefit.

What types of inpatient services does private health cover?

Private health insurance hospital cover policies pay benefits towards a wide range of treatments. While the exact list of procedures and services covered varies depending on the level of cover you choose — basic, bronze, silver and gold — most Australian private health funds pay benefits to cover the following inpatient medical costs:

• Hospital accommodation, including for day surgery and overnight stays
• Theatre and surgical fees
• Doctors' and specialists' fees
• In-hospital pharmaceuticals and dressings
• Surgically implanted prostheses
• Intensive care
• Diagnostic tests

Frequently asked questions

• What is inpatient and outpatient coverage?

  Inpatient coverage is any medical treatment you receive once you have been formally admitted to a hospital, either as a day patient or an overnight patient. Private health insurance (hospital cover) generally provides benefits for these services, alongside Medicare.

  On the other hand, outpatient coverage is medical treatment you receive without being formally admitted to a hospital. Outpatient services are typically conducted in a public hospital clinic, a doctor's consulting room or a community health centre.

• How do I know if I'm an inpatient or outpatient?

  You are an inpatient when you are formally admitted to the hospital for treatment. This usually happens if you are pre-booked for a procedure (like surgery) or if you are critically ill and admitted from the emergency room.

  You are an outpatient if you receive treatment without formal admission, like emergency room treatment where you are not formally admitted to a bed or ward.

• What is not covered by private health insurance in Australia?

  Private hospital cover generally does not cover services where you are treated as an outpatient, such as GP visits, diagnostic services (like X-rays and pathology) and emergency department visits.

  Services like general dental, optical (glasses/contact lenses), physiotherapy, chiropractic treatment and natural therapies are also not covered by standard hospital cover. To receive benefits for these, you must purchase a separate extras cover policy.

Written by

Gary Ross Hunter

Journalist

Gary Ross Hunter has over 6 years of expertise writing about insurance, including life, health, home, and car insurance. Having reviewed hundreds of product disclosure statements and published over 800 articles, he loves simplifying complex insurance topics for everyday readers. Gary has contributed to major outlets like Yahoo Finance, The Sydney Morning Herald, and news.com.au, and holds a Bachelor of Arts (Honours) in English Literature from the University of Glasgow, along with a Tier 2 General Advice certification, ensuring his work adheres to ASIC’s RG146 standards. See full bio

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