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When do I become an in-patient?

In-patient, out-patient, day-patient…I’m confused. What’s the difference and how do I know if my private health insurance will cover me?

We understand that it’s confusing terminology. Let us put you in the picture.

Let’s start at the beginning

Your General Practitioner (GP) is at the frontline of your health care. Sometimes your GP will need to call in some bigger guns and will refer you to a specialist for further assessment or treatment.

Even if your specialist has consulting rooms in a hospital, you are not an admitted patient of the hospital. You might physically be in the hospital, but you’re there for out-patient treatment.

Your out-patient care can be ongoing. It might involve treatment from other medical or diagnostic professionals – even at facilities within the hospital – but you’re still an out-patient.

Costs for out-patients

Medicare will contribute 85% of the Medicare Benefit Schedule (MBS) fee for your out-patient treatment. If your health care provider does not bulk bill, you will be responsible for the remaining balance. And as we know, many specialists charge more than the MBS fee for consultations and treatment.

Many people look to their private health insurer for a helping hand at this point. Unfortunately, legislation prevents health insurers from providing benefits for specialist out-patient treatment.

If your out-patient treatment incorporates allied health services, such as physiotherapy, Medicare will not provide a benefit. In this case, you’ll usually be able to claim a benefit through your private extras cover.

The tip for remembering who pays for what: if Medicare pays a benefit for out-patient treatment, private health insurers cannot.

Now I’m an in-patient

If your out-patient treatment doesn’t resolve your health issue, you might need to be admitted to hospital, whether it’s for a day or overnight. That’s when you become an in-patient.  Even minor procedures, such as surgical tooth extractions in a day-facility count as admitted in-patient treatment.

Costs for in-patients

As an in-patient of a public hospital, your hospital accommodation and medical treatment will be covered by Medicare.  As a public patient you will have nothing to pay. But you may need to wait a long time.

If you have private health insurance you can be admitted to an agreement private hospital and be treated almost immediately. Depending on your level of cover, your insurer will cover 100% of the private hospital accommodation charges (less the excess if you have one). Medicare will contribute 75% of the MBS fee for your doctors’ charges; your insurer will cover the remaining 25%; you will be responsible for any remaining balance.

What about an emergency?

In an emergency you will be taken to the nearest public hospital and receive urgent care based on your level of need.  The cost of your emergency treatment will be covered by Medicare.

If you need further treatment, you may be admitted to the hospital as an in-patient. Or you could be referred to the public hospital’s out-patient clinic for follow-up treatment at a later date.

There is no cost to you for the medically necessary treatment you receive in a public hospital emergency department. Private health insurance benefits are not payable on any emergency treatment – either in a public hospital or private emergency facility.

There you have it – in-patient and out-patient arrangements in a nutshell. Your private extras cover can help out with some out-patient treatment like physio. And your private hospital cover comes to the party for in-patient treatment.

Need to know more about going to hospital? It’s all in this brochure.

Category: Your Insurance


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Article by: Defence Health