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Inpatient and outpatient services

Inpatient services are covered private health insurance, but outpatient services usually aren’t.

An inpatient service is any treatment you receive once you've been formally admitted to a hospital — either as a day or overnight patient. Most treatments are covered by Medicare and private health insurance. Outpatient services, on the other hand, includes anything where you're not formally admitted to hospital and isn't usually covered by your private health insurance.

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:

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

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