Paediatric Care at Birth

Will my private health insurance cover my invoice for my child’s care?

In most cases, Medicare rather than private health insurance covers paediatrician fees, as most babies are not considered to be formally admitted as an inpatient, even though the mother is. As an outpatient, large Medicare rebates apply and generally cover most of the fees for your baby's care as a neonate. . Private health insurance rebates your paediatrician's care provided to babies whilst they are admitted as inpatients of the hospital nursery.


Your baby may be  formally admitted, as a hospital inpatient for phototherapy, oxygen therapy, injected or IV antibiotics, a glucose drip or other need for the closer supervision and care provided in the hospital's nursery. etc. Caesarian birth or a short visit to the special care nursery directly after birth for breathing difficulties or warming up does not qualify as a formal admission.


In the case of formal admission as an inpatient, this portion of the account will normally be invoiced directly to your private health fund. It is important to promptly register your baby for Medicare and on your health fund policy so this can be done in reasonable time. Where your health fund is invoiced, there may be a gap amount not covered and this will then be invoiced to you.

If your family is self insured  or not covered by Medicare (e.g.  overseas visitors), the invoice for your baby's admitted care will be sent to you with  inpatient item numbers  listed with an asterisk (*) next to them for claiming purposes. Once paid, overseas visitors can present their receipt  to their health fund or the self insured registered with Medicare  will be able to claim applicable Medicare rebates .

The hospital said there wouldn’t be other expenses?

That is usually true for the hospital only component, but there may still be other fees for services not directly under the responsibility of the hospital such as anaesthetics, medicine costs, pathology services and other physician  reviews. Your obstetrician will refer your baby, at birth, to a paediatrician  who then undertakes 24/7 medical responsibility for your baby during their stay in hospital. This specialist paediatric care is essential to your baby's stay in the hospital.

How much is the Gap? (Medicare-eligible patients only)

It is hard for us to determine your exact final out-of-pocket expense or ‘gap’ because it depends on your Medicare Safety Net threshold level.

Our current billing policy caps standard  gap (the amount not covered by standard Medicare rebates). This standard gap is determined by the nature of your baby's delivery. Urgent  unplanned attendances involve the most cost and the highest capped gap. Our billing policy is set to ensure families are able to access all applicable rebates. This standard gap is often reduced by additional Medicare Safety Net rebates. Most families find that they are eligibille for these Safety Net rebates Safety Net threshold reduces their capped standard gap, indicated on the invoice, to a much smaller amount.

What is the Medicare Safety Net Scheme and how does it affect me

Once your family has reached a Medicare Safety Net threshold for health care expenses, you will receive additional rebates. Make sure both parents, the baby, and any siblings, are all registered and linked as a family with Medicare, so you get the full benefit of the thresholds. At the first threshold of out of pocket costs in a calendar year, Medicare rebates any further scheduled fees paid in that year. At the second threshold Medicare rebates 80% of the remaining gap. More information about the Safety Net Scheme can be found here.

What is the best method of payment?

We request payment of the account in full and the different payment options are listed on your invoice.

We will then lodge an online Medicare claim on your behalf and rebates are normally paid within 24 hours. 

A Medicare claim requires your child's Medicare number, so it is best to apply for this very soon after birth to avoid a longer wait for your rebates. Ensuring we have up to date information about your baby, such as their correct name,  will help avoid any claiming problems. Phone the rooms or complete the Newborn Registration Form to ensure we have correct details.

Payment of the full amount, followed by our submission of your paid claim, ensures that you receive all applicable rebates, including the additional Medicare Safety Net rebates if your family is eligible.

Staff can advise on payment methods that may reduce the wait for these rebates to a few hours. Families are always most welcome to discuss any concerns about their invoice with practice management.  An itemized payment plan can be arranged, if needed, to minimize financial stress by reducing the size of the outlay needed and the wait for the associated rebate on each day a payment is made.

What if my baby doesn’t have a Medicare number yet?

While we appreciate prompt payment, we understand that there can be delays in receiving your baby’s Medicare number. If this is the case, we are happy to delay payment until the time of your 6-8 week check. However we ask that all accounts are settled by this time.

After your baby’s registration forms have been sent to Centrelink (and Medicare), it can take a number of weeks to receive a number, and additional time to receive the new card in the post. Hence it is important to avoid any delay in submitting these Medicare application forms.

If you are experiencing delays, here are some things to try:

  • Phone Medicare and check that they have received your forms. They may be able to provide you with a number if the baby has already been registered but you haven’t yet received the new card.

  • Go to a Centrelink office with your baby’s birth certificate and any receipts. They can register your baby on the spot and process any claims you need to make.