Outpatient costs and Medicare

Like so many industries, health care and health insurance have their own rules and jargon, and for everyone else that can sometimes be confusing.

For example, do you know the difference in fees for outpatients and inpatients? Who pays for what? And exactly what is an outpatient?

We’ve put together this fact sheet as your general guide, however we encourage you to contact us first to discuss your situation and entitlements, if you are planning a hospital treatment.

Inpatient vs outpatient

In simple terms, you are classified as an inpatient once you are admitted to hospital, whether through emergency or a planned surgery or treatment. This usually means you will be given an ID bracelet, a bed and will sign the National Claim Form. Staying overnight is not mandatory to count as an inpatient.

An outpatient on the other hand covers a broader range of patient-hospital interactions, but the common factor is not being formally admitted to hospital. So, outpatients generally include:

  • Patients whilst in the emergency department, waiting or being treated,
  • Inpatients once discharged, even if having a test or a return check up,
  • Patients visiting a doctor’s or specialist’s rooms within a hospital, and
  • Appointment based hospital treatments such as x-rays, wound dressing, prenatal classes, and physiotherapy.

Hospital costs

As a general guide, if you're an inpatient using private health insurance, Medicare and/or your private health insurance cover will pay for many of your expenses as an inpatient.

HCi covers 100% of your accommodation and theatre costs for eligible inpatient treatments*, but you will likely have to pay for other incidentals you choose (such as TV, newspapers and the like).

For doctor’s fees, pathology, x-rays and so on, Medicare will cover 75% and HCi covers 25% of scheduled fees*.

However, as an outpatient, you may incur some costs (other than within the emergency department). Medicare and your health care extras cover may cover part of some treatments, such as x-rays and doctor’s fees, but there is a good chance you will have some out of pocket expenses to pay.

Those out of pocket expenses cannot be claimed as expenses against your HCI policy as an outpatient.

The following chart summarises the differences for inpatient and outpatient costs.

InpatientOutpatient

Public emergency department care

Not applicable as an inpatient

Medicare

Private emergency department care

Not applicable as an inpatient

Medicare and you

Private hospital accommodation and meals

HCi

Not applicable

Public hospital accommodation and meals

Medicare

Medicare

Hospital incidental costs

You

You

Theatre costs

HCi

Medicare

Doctor fees whilst at hospital

HCi 25% & Medicare 75% of schedule fee*

You and Medicare

Doctor fees before and after your hospital visit

You and Medicare

You and Medicare

Pathology and x-ray services while in hospital

HCi 25% & Medicare 75% of scheduled CMBS fee*

You

Gap between the scheduled fee and your doctor’s fees

You

You

* Some doctors charge more than what Medicare deems “an appropriate fee”, in which case you will be responsible for paying any amount above the Government’s scheduled fee. The schedule fees are the fees set out in Commonwealth Medical Benefits Schedule – see What to do if I have out-of-pocket expenses? for additional information.

This fact sheet is general information only. All private health insurance claims are subject to eligibility conditions, including your level of cover, completion of waiting periods, consideration of pre-existing conditions and any other restrictions relevant to your cover.

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