Hospital ward fees for labour, intensive care and surgery

How are hospital fees determined?

The costs you may have to pay during a stay in hospital include consultations, equipment use, the facilities you take advantage of and the treatments you undergo.

How do the hospitals get paid?

• Public hospitals get paid by the government for treating public patients with essential medical services.
• Public hospitals are paid by the government to provide private patients with essential medical treatment, but will also charge the difference between this benefit and the cost of their services.
• Private hospitals only accept private patients and do not get paid by Medicare. All private hospital costs must be paid by the patient or their private health fund.

Some of the extra fees that can be incurred depend on which hospital services you use while there. Some of the big ones are:

• Accommodation. Most private health funds offer cover for private rooms at private hospitals, while some will also pay extra benefits if you use a shared room at a public hospital.
• Ward fees. Some policies cover specific ward fees such as intensive care but not labour. The ward fees covered by private health funds usually depend on the comprehensiveness of the cover.
• Ambulance cost. If you live in Queensland or Tasmania your ambulance costs will covered by the state government. If you live anywhere else, you’ll need health insurance to cover the costs of emergency ambulance.
• Non-essential general treatments. Many hospitals offer additional non-essential services like physiotherapy, counselling, occupational therapies, psychology or psychiatric services and others. Because these are not strictly medically necessary they are not covered by Medicare. They are typically covered to varying extents by private health insurance extras policies.
• Incidentals. These are optional luxuries or additions you might choose to take advantage of while in hospital and are usually minor things like having a TV in your room or getting a newspaper delivered to your bed. Some private health funds will offer an “allowance” for these, but others will not cover them at all.

Costs for giving birth in a hospital

With private health insurance

Many mothers-to-be prefer to use private health funds to cover labour or maternity ward fees and related expenses. This is because they are then able to choose a private hospital, or be admitted as a private patient to a public hospital where they have more freedom to choose their doctor and services.

• Ward fees are covered under private health insurance policies. However, this typically requires selecting and paying for a more comprehensive option, as most basic hospital policies do not include it.
• Procedures like anaesthesia will typically be covered under general or core sections of health insurance policies. As a private patient in a public hospital this can cover the gap between what Medicare subsidises and what the hospital actually charges. As a private patient in a private hospital, you cannot access Medicare subsidies and must either pay out of pocket, use health insurance or do a combination of the two to pay for essential procedures.
• Extras may include assistance in the form of birthing classes, coaching, pre and postnatal therapies, additional check-ups and other non-essentials to promote health and aid recovery following birth. These may require health insurance extras policies.
• If the health insurance fund has a network of affiliated hospitals then you may be required to choose one of these to claim benefits.

Under Medicare

Medicare will cover labour ward fees and essential costs for public patients in public hospitals. Particular birth-related procedures are covered when deemed medically necessary or recommended by a specialist obstetrician or professional in a related area. The costs covered include:

• Antenatal attendance, which is care provided before giving birth
• Anaesthesia if applicable
• Labour, birth and related staff and facilities
• The creation of a maternity care plan after 20 weeks of pregnancy
• A comprehensive postnatal (after birth) check-up six weeks after giving birth
• Caesarian sections, use of forceps or vacuum devices and other assisted birth procedures if necessary, and related costs like anaesthesia and additional recovery time
• Episiotomy, or repair of tears

In general, Medicare covers the essential costs involved in safely giving birth and reducing pain and discomfort.

How much does the intensive care unit cost?

With private health insurance

The way your private health insurance covers ICU costs depends on the type of policy you have and your insurer. Some basic policies will not cover any ICU ward costs and are generally intended for patients who will opt for public, not private, hospitals. However, more comprehensive policies will typically cover intensive care ward fees.

• Ward fees are additional expenses on top of the actual treatment costs.
• Some health insurance hospital policies will cover ICU ward fees while others will not. Generally speaking, the majority will. Basic policies are less likely to cover intensive care ward fees, while comprehensive policies are very likely to cover ICU ward fees.
• Almost all medical procedures carried out in the ICU are medically essential. This means they will rarely be excluded in the terms and conditions of your policy.
• Whether or not they are medically essential, your health insurance policy will only cover certain treatments. The procedures covered depend on the type of policy you have taken out. More comprehensive ones cover more eventualities.
• Many insurers have a network of partner hospitals. You may be required to select one of these to claim ward fees and related benefits.

Under Medicare

Under Medicare, an intensive care unit is defined as a facility that fulfils specific requirements. Having these facilities lets a public hospital classify the ward as an intensive care unit, and therefore claim government Medicare funding for emergency treatments carried out there. An intensive care unit must:

• Be a separate hospital area
• Have the equipment and staff to provide breathing assistance and heart monitoring to patients for days on end
• Be supported around the clock by at least one immediately available intensive care specialist, one dedicated ICU doctor and by a registered nurse for at least 18 hours a day
• Have a defined set of conditions determining when a patient is admitted to and discharged from the ICU

If you are admitted to the intensive care unit in a public hospital then the particular treatments you receive there are typically all covered by Medicare. If you are in a private hospital or are a private patient in a public hospital then you will typically need to pay out of pocket or use private health insurance to pay for the costs.

If you were immediately taken to the ICU in an emergency situation or were unconscious during, then you were generally admitted as a public patient, and Medicare will cover treatment and ward costs as applicable.

Are there operating theatre fees?

Operating theatres are special rooms in hospitals that are dedicated to carrying out surgery. Unlike the labour ward or ICU they are not necessarily an entirely separate part of the hospital, but they also incur extra costs like ward fees. Operating theatres must be meticulously sterilised and disinfected after each operation, and almost all surgery requires attention from specialists like anaesthetists, attending nurses and of course the surgeons. These account for the additional operating theatre fees.

With private health insurance

Most private health insurance funds will cover operating theatre fees, if not the procedure itself, with mid-level and comprehensive hospital policies. Many, but not all, will also cover it with basic hospital plans. Whether the surgery itself is covered will depend on the type of surgery and its purpose, as well as your hospital and insurer.

• Operating theatre fees are covered by many but not all private health insurance hospital policies.
• The more comprehensive private health fund policies are fairly likely to offer a certain level of cover for elective procedures, even things like cosmetic surgery.
• If your insurer has a network of affiliated hospitals then you may be required to select one of these in order to claim certain benefits like ward fees or even the cost of the procedures themselves.

Under Medicare

Medicare will cover operating theatre fees in the event of essential or emergency operations, as well as the costs of the surgery itself. The public hospital will typically claim these costs directly themselves. If you are a private patient in a public hospital then the costs will typically be covered up to the predefined Medicare benefits, but the hospital might charge you the difference between this and their actual fees. In a private hospital, you will generally be charged the complete cost, for both procedures and operating theatre ward fees, which you may be able to claim on private health insurance.

• Medicare covers essential and emergency surgeries, as well as the anaesthesia and other essentials.
• Medicare also covers the operating theatre fees for essential procedures.
• While it is possible to get useful elective surgeries at public hospitals as public patients, such as joint replacement surgery, these are not considered strictly essential and will, therefore, have very long waiting times, sometimes months or more. The extent to which Medicare covers these and related operating theatre fees will depend on the circumstances.