The costs of having a baby Private system
Contents Introduction 4 Weeks 1 4 5 Week 5 5 Week 6 6 Week 10 6 Week 11 7 Week 12 8 Week 15 8 Week 16 9 Week 20 9 Week 21 10 Week 22 10 Week 26 11 Week 32 11 Week 34 12 Week 36 12 Week 38 12 Week 39 13 Week 40 13 Week 46 15 Approximate average totals 15 Table of costs 16 Sources and useful links 19
Introduction Having a baby is an exciting time. No doubt most new parents will be faced with many questions, one of them being: what does it really cost to have a baby? Well, depending on which way you choose to go, health system costs can vary, so it s worth understanding what you might be up for. This guide provides an example of the costs you might expect if you use your private health insurance during pregnancy, as a private patient in a private hospital. It s important to understand that this guide assumes you have a level of cover that includes obstetrics. Obstetrics is not covered on every health cover and a 12 month waiting period applies if you are a new customer or have just moved to a cover that includes obstetrics. On some nib health covers a benefit limitation period may also apply to new customers (this means you ll receive only restricted benefits after your 12 month waiting period and up to a period of 24 months). So if you re planning a baby, and you d like to use your health insurance to go to a private hospital, you ll need to be on a health cover that includes obstetrics at least 3 months before you start trying to fall pregnant. We recommend that you call nib on 13 14 63 to ensure you have an appropriate level of cover. This information has been developed with the help of some of the following sources: Australia Private Health Australia PHIO Obstetrics Fact Sheet PHIO Informed Financial Consent NSW Health Royal Australian College of General Practitioners The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) www.birth.com.au www.babycenter.com.au www.bubhub.com.au/index.php www.bellybelly.com.au One thing most people don t know is that in Australia, private health insurance will often only cover you for in-hospital services. This means most medical expenses during pregnancy will not be covered by your nib health cover until you arrive in the hospital to have your baby (but they may be covered, at least in part, by ). Private health insurance doesn t normally cover you for outpatient services such as GP and Obstetrician visits, scans or blood tests. The GP and specialist costs in this guide are an approximate average range of costs in Australia. These costs vary greatly depending on your choice of specialist and where you live (GPs and specialists in metro areas typically charge higher fees). The in-hospital obstetrics costs, private health insurance benefits paid and out-of-pocket amounts are based on an approximate average of nib customer claims data for an uncomplicated pregnancy and industry averages for the year 2013. All out-of-pocket costs should be viewed as a guide only. There s also some information and a few tips that may help you avoid some out-of-pocket costs during your pregnancy. For more information we suggest you give nib a call on 13 14 63 to discuss your options. The information contained in this study is of a general nature only. It is not based on your personal circumstances and needs. You should consider whether the information in this study is appropriate having regard to your circumstances and needs. To obtain advice or more information about any of these topics you should speak to a GP, Obstetrician or maternal health professional. Important: All costs in this guide are of an indicative nature only. The costs were correct as at January 2014 and change annually. We recommend you consult your health professionals for current prices. 3
Weeks 1 4 So you think you might be pregnant? The first thing to do is visit your GP who is likely to conduct a urine test to confirm your pregnancy and screen for a urinary tract infection. Pregnancy and urinary tract infections often go hand in hand as pregnancy hormones put women at an increased risk to develop UTIs. At this appointment your GP may also provide you with a referral for your first routine blood test, which can be done any time, but is best done as early as possible in your pregnancy. You will need ongoing care throughout your pregnancy and your GP may be able to provide a referral to an Obstetrician (OB) of your choice. Ask your GP to supply a list of Obstetricians in your area. Once you have created a shortlist of Obstetricians, we recommend that you give some or all of them a call and ask the following questions: 1. Are they taking additional patients? 2. At which hospitals do they deliver? 3. Is that a public or a private hospital? 4. Can they provide a rough guide to their fees and charges for the planning and management of your pregnancy? 5. Do they participate in nib s MediGap scheme? Or otherwise cap their fees? We also recommend asking what arrangements your Obstetrician has if he/she is away at the time of your delivery. GP Consultation MBS items 5040, 2546 Time based $36.30 for 15 minute consultation $36.30-$100 Time based $36.30 for 15 minute consultation $0 $0-$63.70 Your notes: Weeks 1 4 Week 5 Once you have narrowed down your shortlist of Obstetricians to one or two, give us a call on 13 14 63 to find out: 1. If the hospitals the OB works in are under contract with nib. You are likely to have significant out-of-pocket expenses if your OB of choice performs at a hospital not under contract with nib. 2. We can confirm whether they have participated in nib s MediGap Scheme in the past. Once you ve decided on your OB, and checked the relevant details (from Week 4) with us, you can give the Obstetrician a call and ask to be booked in as a patient. Your first OB appointment is likely to be 10-12 weeks into your pregnancy. You will make a schedule of appointments approximately once a month until you are 32 weeks along and then around every fortnight until 38 weeks. After this you ll meet once per week until you give birth. Your notes: Week 5 4
Week 6 Around this time you may be due for your first routine blood test to check that you and your baby are healthy. This blood test will vary depending on your age and risk profile, but will usually test for things such as blood group and antibodies, rubella and hepatitis B and C. Other things that you might be tested for include Syphilis (which is mandatory in most states), haemoglobin, HIV (mandatory at many hospitals) and Varicella Zoster ( chicken pox ). If necessary, you may need another appointment with your GP to discuss your results. GP Consultation MBS items 5040, 2546 Time based $36.30 for 15 minute consultation $36.30-$100 Time based $36.30 for 15 minute consultation $0 $0-$63.70 Blood Screening* MBS items 65165, 69415 $34.70-$69.55 $34.70-$222 $29.50-$59.15 $0 $5.20-$152.45 * Fee is approximate average cost which varies depending on what is being tested. Your notes: Week 6 Week 10 In or around week 10 you may be due for the first consultation with your OB. At this appointment they should supply you with a schedule of ongoing fees and charges that you can expect to pay as part of their management of your pregnancy. This may include costs for: Ongoing consultation fees Ultrasounds Blood test/screenings Planning and management fee Delivery fee. Your private health insurance only covers the cost of the delivery fee in hospital; the other costs may, however, be covered in part by. We recommend you ask for informed financial consent from your OB. This just means that you both agree on the set charges for services throughout your pregnancy, so you know what you will be paying in advance. Be sure to also check with them: What happens regarding their fees if you experience complications during your delivery (or if you deliver outside of standard business hours e.g. middle of the night or a public holiday) What happens if you require an anaesthetist and how you can understand their costs upfront What happens if your baby experiences complications and has to be admitted to hospital. First OB Consultation MBS item 16401 $85.55 $150-$333 85% ($72.75) $0 $77.25-$260.25 5
Your notes: Week 10 Week 11 Around this time you may be due to have your First Trimester Screening. This is entirely optional and will involve a blood test and ultrasound to test for your baby s risk of Down Syndrome, other abnormalities such as Spina Bifida and to detect multiple pregnancies. If you elect to have this test you may have received a referral from your OB at your initial consultation for this screening. Blood Screening* MBS items 65165, 69415 Ultrasound MBS item 55759 $34.70-$69.55 $34.70-$222 $29.50-$59.15 $0 $5.20-$162.85 $150 $150-$333 85% ($127.50) $0 $22.50-$205.50 * Fee is approximate average cost which varies depending on what is being tested. Your notes: Week 11 In or around week 10 you may be due for the first consultation with your OB. At this appointment they should supply you with a schedule of ongoing fees and charges. 6
Week 12 If the results of your First Trimester Screening show an at increased risk of Down Syndrome or other chromosome abnormality, a diagnostic test and/or genetic counselling may be recommended. The tests may be conducted as follows: Chorionic Villus Sampling (CVS) through the abdomen or cervix MBS item 16603 Amniocentesis (through the abdomen) this may be conducted at Week 14 or 15 MBS item 16600 $121.85 $550-$1,110 85% ($103.60) $0 $446.40-$1,006.40^ $63.50 $550-$1,110 85% ($54) $0 $496-$1,056^ ^ Unless your First Trimester Screening indicated that you have an increased risk of Down Syndrome or other chromosomal abnormalities you will not be required to pay for these tests. Note: The cost of genetic tests such as CVS and Amniocentesis depends on whether it is conducted in a public or private facility. Karyotyping and Fluorescent in Situ Hybridization (FISH) are specific types of diagnostic or results analysis conducted by a laboratory. This type of analysis carries an additional charge to standard test analysis, and has a rebate of $319.15 if elected. The FISH procedure has no rebate and the cost varies considerably from $50 to about $400 at different laboratories. We recommend you discuss these options with your OB. Your notes: Week 12 Week 15 You may be due to have your Second Trimester Screening. This is entirely optional and can be available to women who are too late for the First Trimester Screening test, or if the First Trimester Screening test is not available in their area. This is usually a blood test that provides information on your baby s risk of developing Down Syndrome or Spina Bifida. This may be called a Maternal Serum Screen (MSS) or Triple Test. Blood Screening* MBS items 65165, 69415 $34.70-$69.55 $34.70-$222 $29.50-$59.15 $0 $5.20-$162.85 * Fee is the approximate average cost which varies depending on what is being tested. Your notes: Week 15 7
Week 16 Your notes: Week 16 Week 20 At around 20 weeks, you may be due for an ultrasound and your OB may have given you a referral. This will check for the position of the placenta, the amount of amniotic fluid, baby s growth and detect any structural abnormalities in the foetus such as heart, limbs, abdomen, bones, brain, spine and kidneys. 20 week structural ultrasound MBS item 55759 $150 $150-$333 85% ($127.50) $0 $22.50-$205.50 Antenatal Classes $0 $50-$400 $0 $0-$400^ $0-$400^ ^ Your PHI benefit for antenatal classes will depend on your level of cover and who provides the class. We recommend that you call nib on 13 14 63 before you book your classes and we can let you know if you ll have any out-of-pockets to pay. At this time you re also likely to have another visit to your OB. At this visit your OB is likely to carry out a standard check-up to. It s a good idea to ask which hospital to book into for the birth (if you have not already done so), and ask what fees and charges you should expect for your delivery in that hospital. Ask your OB s office to supply the paperwork required to book your place in the private hospital. It is also time to book your antenatal classes. You are likely to commence classes around 32 weeks or earlier into your pregnancy. These will generally involve around 4-6 visits, depending on availability and other factors. Antenatal classes are not covered by, but may be covered by your private health insurance. It s best to call us and check whether your classes are covered. Once you have completed the forms, contact the hospital. You may need to meet with an admissions officer to provide them with your paperwork. They may also show you the facilities and discuss any details of your hospital stay. 8
Your notes: Week 20 Week 21 You should expect a call from your hospital as it will have completed an eligibility check with us just to ensure you have the appropriate level of hospital cover for pregnancy and birth related services in a private hospital. You will also need to ensure your payments to nib are up to date so you are fully covered. The hospital will then advise of any costs you can expect which may include your hospital excess that may be payable now, or anytime up to your hospital admission. Your notes: Week 21 Week 22 Note: At 24-26 weeks a glucose challenge test is usually performed. If this is positive, your GP or specialist will proceed to an Oral Glucose Tolerance Test to screen for gestational diabetes. Your notes: Week 22 9
Week 26 Your OB Planning and Management Fee may be due this visit MBS item 16590 $324.10 $1,600-$4,500 85% ($275.50) $0 $1,324.50-$4,224.50 Your notes: Week 26 Week 32 Your notes: Week 32 At week 21 your hospital will advise you of any costs you can expect to pay either now, or anytime up to your hospital admission. 10
Week 34 Your notes: Week 34 Week 36 Your notes: Week 36 Week 38 Your notes: Week 38 11
Week 39 Your notes: Week 39 Week 40 You may be due to have your baby! You may need to pay your hospital excess (if you have one) upon admission to hospital, though many hospitals will ask you to pay earlier than this to confirm your booking. The hospital will put this amount towards your hospital fees, which will be billed directly to nib at the end of your stay. s In Week 5 you called nib to confirm your health cover and check your preferred hospital was contracted to nib and in Week 10 we recommended that you ask your Obstetrician (and if possible your anaesthetist) for informed financial consent. Informed financial consent is your right and will help you understand what out-of-pocket costs to expect during your delivery. In Week 26 you paid your Obstetrician s Planning and Management Fee. Part of this can be claimed via but for the most part it s an out-of-pocket expense. And throughout your pregnancy you have contributed part of the cost of ultrasounds, blood tests and consultations with your Obstetrician (these services are not fully covered by and cannot be claimed through health insurance). A table outlining these costs can be found at the end of this guide. If you receive a bill from your hospital after you ve had your baby it may mean that you had additional out-of-pocket expenses during your stay. These may have happened if: Your Obstetrician and Anaesthetist (if you required one) decided not to participate in nib s medical gap scheme to eliminate out-of-pocket expenses You required blood tests, scans, ultrasounds or other items that are not covered by nib s hospital contract You used an ambulance for transport to/from/between hospitals when it was not medically necessary You or your baby had complications and were admitted as a private patient (if the opportunity is available you can ask to be admitted to a public hospital as a public patient to avoid unforeseen costs). You will also have an out-of-pocket cost for the Paediatrician who comes to check your newborn. Your healthy newborn baby is considered an outpatient. Health insurance cannot cover this service and will only pay part of the cost. The following table outlines the costs faced by the majority of nib customers for an uncomplicated pregnancy. It assumes you have obstetrics cover and attend an nib Agreement Private Hospital. We have excluded the bottom 5% and top 5% of claims to give the most realistic picture of the costs most customers should expect. 12
Week 40 cont d Delivery Fee for your Obstetrician (uncomplicated delivery) MBS item 16519 nib Agreement Private Hospital Charges (uncomplicated delivery) Anaesthetist (uncomplicated delivery) Average of all claims associated with an uncomplicated delivery Paediatric Consultation for your newborn (no complications) MBS item 110 Hospital Excess (if you have one) Doctor, Specialist or Hospital Cost $693.95 $1,252 -$1,518 75% ($520.50) 25% (minimum benefit $173.45) On average nib pays $933 (includes MediGap) $0 $3,419-$8,023 $0 $3,419-$8,023 $0** $274.67-$738.67 $417-$1,540 75% ($206-$554) $150.90 $250-$400 85% ($128.30) 25% (minimum benefit $68.67-$184.66) On average nib pays $234 (includes MediGap) $0*-$824.05 96% of nib customers have no out-of-pockets for their delivery fee. Of the 4% of customers who did have an out-of-pocket the average was $1,053 for a vaginal delivery $682 for a caesarean delivery $0*-$1,265.33 49% of nib customers have no out-of-pockets for their anaesthetist Of the 51% of customers who did have an out-of-pocket the average was $491 for a vaginal delivery $727 for a caesarean delivery $0 $121.70-$271.70 $0 $0 $0 $0 $0-$500 nib s most popular excess level is $500 * If your specialist elects to charge the Benefit or participate in nib s MediGap scheme to eliminate out-of-pocket expenses. ** No out-of-pockets assumes that you give birth in a private hospital under contract with nib. If you require items that are outside of nib s hospital contract you may have out-of-pockets to pay. Please note that if you do not have health insurance and elect to attend a private hospital to have your baby your hospital charges are likely to be significantly higher than the charges you would experience as an nib private hospital patient. Your notes: Week 40 13
Week 46 Post-partum check-up by midwife/ob assist or your GP $43 $80-$167 85% ($36.55) $0 $43.45-$113.45 Note: This is an outpatient service and unable to be covered by private health insurance. Your notes: Week 46 Approximate average totals Approximate average totals $2,492-$2,685 $9,170-$29,600 $2,022-$2,111 $4,316-$10,666 $2,445-$8,355 (based on nib s average claims experience your outof-pockets could be higher or lower depending on your circumstances) Tips to help you avoid out-of-pockets If your specialists participate in nib s medical gap scheme, it is likely that and nib will pay for 100% of hospital costs; however, your specialist, OB or Anaesthetist may charge more than the benefit schedule fee in which case you may have an out-of-pocket cost. If your hospital does not have an agreement with nib, you are more likely to incur out-of-pocket costs. Contact to discuss the Safety Net, your limits and what you can do to get the most benefits. Ask your specialists for Informed Financial Consent of their fees and charges. Be prepared for additional costs if there is an emergency or complications. It s unlikely that you ll have a choice of doctor in these situations; as a result it s difficult to check whether they participate with a medical gap scheme and you are likely to end up with out-of-pockets as a result. Don t forget you can still ask them to consider medical gap even after the service. Remember that your new, healthy baby will be considered an outpatient and any consultations or tests related to your newborn while you are both in hospital will not be covered by your nib health cover. The Extended Safety Net (EMSN) no longer covers 80% of the out-of-pocket costs for obstetrics. There is a cap on the benefit paid to obstetrics claims under the Extended Safety Net which generally increases out-of-pocket expenses during pregnancy. Limitations to the Extended Safety Net are detailed here www.health.gov.au/internet/mbsonline/publishing.nsf/content/factsheet-extendedsafetynet_aug2014 14
Table of costs Week 1-4 GP Consultation MBS items 5040, 2546 Week 6 GP Consultation MBS items 5040, 2546 Blood Screening MBS items 65165, 69415 Week 10 First OB Consultation MBS item 16401 Week 11 Blood Screening MBS items 65165, 69415 Ultrasound MBS item 55759 Week 12 Chorionic Villus Sampling (CVS) through the abdomen or cervix MBS item 16603 Amniocentesis (through the abdomen) this may be conducted at Week 14 or 15 MBS item 16600 Week 15 Blood Screening MBS items 65165, 69415 Week 16 Week 20 20 week structural ultrasound MBS item 55759 Time based $36.30 for 15 minute consultation Time based $36.30 for 15 minute consultation $36.30- $100 Time based $36.30 for 15 minute consultation $36.30-$100 Time based $36.30 for 15 minute consultation $0 $0-$63.70 $0 $0-$63.70 $34.70-$69.55 $34.70-$222 $29.50-$59.15 $0 $5.20-$162.85 $85.55 $150-$333 85% ($72.75) $0 $77.25-$260.25 $34.70-$69.55 $34.70-$222 $29.50-$59.15 $0 $5.20-$162.85 $150 $150-$333 85% ($127.50) $0 $22.50-$205.50 $121.85 $550-$1,110 85% ($103.60) $0 $446.40-$1,006.40^ $63.50 $550-$1,110 85% ($54.00) $0 $496-$1,056^ $34.70-$69.55 $30-$222 $29.50-$59.15 $0 $5.20-$152.45 $150 $150-$333 85% ($127.50) $0 $22.50-$205.50 Antenatal Classes $0 $0-$400 $0 $50-$400^ $0-$400^ Week 22 15
Week 26 Your OB Planning and Management Fee may be due this visit MBS item 16590 $324.10 $1,600-$4,500 85% ($275.50) $0 $1,324.50-$4,224.50 Week 32 Week 34 Week 36 Week 38 Week 39 Week 40 Delivery Fee for your Obstetrician (uncomplicated delivery) MBS item 16519 $693.95 $1,252-$1,518 75% ($520.50) 25% (minimum benefit $173.45) On average nib pays $932 $0*-$824.05 96% of nib customers have no out-of-pockets for their delivery fee Of customers who did have an out-of-pocket the average was: $1,053 for a vaginal delivery $682 for a caesarean delivery nib Agreement Private Hospital Charges (uncomplicated delivery) $0 $3,419-$8,023 $0 $3,419-$8,023 $0** Anaesthetist (uncomplicated delivery) Based on all items associated with uncomplicated delivery $274.67- $738.67 $417-$1,540 75% ($206-$554) 25% (minimum benefit $68.67-$184.66) On average nib pays $234 (includes MediGap) $0*-$1,265.33 49% of nib customers have no out-of-pockets for their anesthetist Of the 51% of customers who did have an out-of-pocket the average was: $494 for a vaginal delivery $727 for a caesarean delivery 16
Table of costs (cont d) Week 40 (cont d) Paediatric Consultation for your newborn (no complications) MBS item 110 Hospital Excess (if you have one) $150.90 $250-$400 85% ($128.30) $0 $125-$275 $0 $0 $0 $0 $0-$500 nib s most popular excess level is $500 Week 46 Post-partum check-up by midwife/ob assist or your GP $41.35 $80-$167 85% ($35.15) $0 $43.45-$113.45 Approximate totals $2,319-$2,888 $8,365-$19,943 $1,886-$2,323 $3,746-$9,590 $2,022-$11,407 Based on nib s average claims experience your outof-pockets could be higher or lower depending on your circumstances. ^ Unless your First Trimester Screening indicated that you have an increased risk of Down Syndrome or other chromosomal abnormalities you will not be required to pay for these tests. Your PHI benefit for antenatal classes will depend on your level of cover and who provides the class. We recommend that you call nib on 13 14 63 before you book your classes and we can let you know if you ll have any out-of-pockets to pay. * If your specialist elects to charge the Benefit or participate in nib s MediGap scheme to eliminate out-of-pocket expenses. ** You will have out-of-pockets if you require items that are not covered by nib s hospital contract. Your notes: 17
Sources and useful links Australia www.medicareaustralia.gov.au The Extended Safety Net factsheet www.health.gov.au/internet/mbsonline/publishing.nsf/content/factsheet-extendedsafetynet_aug2014 Private Health Australia www.privatehealth.gov.au/ PHIO Obstetrics Fact Sheet www.phio.org.au/facts-and-advice/obstetrics-factsheet.aspx Informed Financial Consent www.phio.org.au/facts-and-advice/informed-financial-consent.aspx Central Coast Division of General Practitioners www.ccnswml.com.au Eastern Sydney Division of General Practitioners www.esml.org.au NSW Health www.health.nsw.gov.au/kids/publications/having-a-baby.pdf Eastern Health www.ruralhealth.unimelb.edu.au Royal Australian College of General Practitioners www.racgp.org.au/afp/200303 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) www.ranzcog.edu.au Government of Western Australia Department of Health www.health.wa.gov.au/home www.birth.com.au www.babycenter.com.au www.bubhub.com.au/index.php www.bellybelly.com.au 18
Need help? Call us on 13 14 63 Mon to Fri: 8am 8.30pm Sat: 8am 1pm (AEST) Visit an nib Retail Centre Go to nib.com.au nib health funds limited abn 83 000 124 381 Head Office 22 Honeysuckle Drive Newcastle NSW 2300 nib277101/0005_1114