Silver health insurance policies
A guide to Silver health insurance
Updated 26 March, 2024
Why do health insurance tiers exist?
To make health insurance simpler, the Australian Government introduced Private Health Insurance Reforms in 2019.
These reforms categorised all private hospital policies into four different tiers (Basic, Bronze, Silver and Gold) and three subset tiers (Basic+, Bronze+ and Silver+).
Each tier includes a certain number of clinical categories and their associated hospital treatments and services. As you go up through the tiers, each includes more clinical categories and a broader range of hospital treatments.
So, what exactly will Silver tier policies include? And why should you consider a Silver policy rather than Gold or Bronze? Let’s find out more about the Silver hospital insurance tier.
What is Silver hospital insurance?
Silver hospital cover sits between Gold and Bronze and includes 26 of 38 clinical categories which must be unrestricted. With a Silver tier hospital insurance policy, you’ll be able to claim a benefit as a private patient in a private or public hospital for the hospital treatments listed under the included clinical categories. In addition to this, Silver hospital policies must include restricted cover for in-hospital psychiatric services, in-hospital rehabilitation and palliative care.
When you’re treated in a private hospital with private hospital cover, you’ll have access to your choice of available doctor and a private room (subject to availability). Your health fund will also pay towards other expenses associated with your hospital admission, such as accommodation and theatre fees. However, this doesn’t always mean you’ll have no out-of-pocket expenses. While Medicare and your health fund will together pay 100% of the Medicare Benefits Schedule (MBS) fee for your treatment, you may have out-of-pocket expenses if your doctor charges above the MBS; this is known as ‘the gap’. However, you may be able to avoid this additional cost if you’re treated in an agreement hospital that participates in your fund’s no-gap scheme.
Expert tips on Silver health insurance
Our health insurance expert, Steven Spicer, knows how hard it can be to pick the right hospital insurance for you. Which is why he’s put together these tips on how to choose your tier.
Steven Spicer
Executive General Manager – Health, Life & Energy
You can switch at any time
There are no lock-in contracts when it comes to health insurance, so you can upgrade or downgrade your policy at any time as your needs change. However, you will be required to serve a waiting period for any upgrades to your hospital insurance policy.
Compare your options
The cost of a standard Silver policy can vary from fund to fund, so it’s a good idea to compare your options prior to purchasing health insurance to ensure you have found the best option for your needs.
Consider your waiting periods
If you’re transferring from another fund, you won’t be required to re-serve any waiting periods. Any waiting periods that you have already served will carry across to the new fund, meaning that you’ll only need to serve a waiting period for any upgrades to your hospital insurance policy. If you haven’t yet completed a waiting period, the time you’ve already served will be applied to your new policy.
Inclusions and exclusions
What does Silver health insurance cover?
Silver tier policies include 26 unrestricted clinical categories and their respective hospital treatment within the scope that’s outlined by the Department of Health, as shown below.
If you live in a state where the government doesn’t cover emergency ambulance services (e.g. NSW, VIC and SA), you may also have ambulance cover included in your Silver tiered policy.
| Minimum requirements for a Silver tier policy: | |
|---|---|
| Rehabilitation (✔R) | Hospital treatment for physical rehabilitation related to surgery or illness. For example, inpatient and admitted day patient rehabilitation, stroke recovery and cardiac rehabilitation. |
| Hospital psychiatric services (✔R) | Hospital treatment for the treatment and care of patients with psychiatric, mental, addiction or behavioural disorders. For example, psychoses such as schizophrenia, mood disorders such as depression, eating disorders and addiction therapy. |
| Palliative care (✔R) | Hospital treatment for care which provides quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain. |
| Brain and nervous system (✔✩) | Hospital treatment for the investigation and treatment of the brain, brain-related conditions, spinal cord and peripheral nervous system. For example, strokes, brain or spinal cord tumours, head injuries, epilepsy and Parkinson’s disease. |
| Eye (not cataracts) (✔✩) | Hospital treatment for the investigation and treatment of the eye and the contents of the eye socket. For example, retinal detachment, tear duct conditions, eye infections and medically managed trauma to the eye. Cataract procedures are listed separately under ‘Cataracts’, which is only covered in the Gold hospital cover. |
| Ear, nose and throat (✔✩) | Hospital treatment for the investigation and treatment of the ear, nose, throat, middle ear, thyroid, parathyroid, larynx, lymph nodes and related areas of the head and neck. For example, damaged eardrums, sinus surgery, removal of foreign bodies, stapedectomy and throat cancer. |
| Tonsils, adenoids and grommets (✔✩) | Hospital treatment of the tonsils, adenoids and insertion or removal of grommets. |
| Bone, joint and muscle (✔✩) | Hospital treatment for the investigation and treatment of diseases, disorders and injuries of the musculoskeletal system. For example, carpal tunnel, fractures, hand surgery, joint fusion, bone spurs, osteomyelitis and bone cancer. |
| Joint reconstructions (✔✩) | Hospital treatment for surgery for joint reconstructions. For example, torn tendons, rotator cuff tears and damaged ligaments. Joint replacement surgery is listed separately under ‘Joint Replacements’, which is only included in the Gold tier. |
| Kidney and bladder (✔✩) | Hospital treatment for the investigation and treatment of the kidney, adrenal gland and bladder. For example, kidney stones, adrenal gland tumours and incontinence. Dialysis is listed separately under ‘Dialysis for chronic kidney failure’, which is only included in the Gold tier. |
| Male reproductive system (✔✩) | Hospital treatment for the investigation and treatment of the male reproductive system, including the prostate. |
| Digestive system (✔✩) | Hospital treatment for the investigation and treatment of the digestive system, including the oesophagus, stomach, gall bladder, pancreas, spleen, liver and bowel. For example, oesophageal cancer, irritable bowel syndrome, gall stones and haemorrhoids. |
| Hernia and appendix (✔✩) | Hospital treatment for the investigation and treatment of a hernia or appendicitis. Digestive conditions are listed separately under ‘Digestive system’. |
| Gastrointestinal endoscopy (✔✩) | Hospital treatment for the diagnosis, investigation and treatment of the internal parts of the gastrointestinal system using an endoscope. For example, colonoscopy, gastroscopy and endoscopic retrograde cholangiopancreatography (ERCP). Non-endoscopic procedures for the digestive system are listed separately under ‘Digestive system’. |
| Gynaecology (✔✩) | Hospital treatment for the investigation and treatment of the female reproductive system. For example, endometriosis, polycystic ovaries, female sterilisation and cervical cancer. |
| Miscarriage and termination of pregnancy (✔✩) | Hospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy. |
| Chemotherapy, radiotherapy and immunotherapy for cancer (✔✩) | Hospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours. Surgical treatment of cancer is listed separately under each body system. |
| Pain management (without a device) (✔✩) | Hospital treatment for pain management that doesn’t require the insertion or surgical management of a device. For example, treatment of nerve pain and chest pain due to cancer by injection of a nerve block. Pain management using a device (e.g. an infusion pump or neurostimulator) is listed separately under ‘Pain management with device’, which is only included in the Gold tier. |
| Skin (✔✩) | Hospital treatment for the investigation and treatment of skin, skin-related conditions and nails. For example, melanoma, minor wound repair and abscesses. The removal of foreign bodies and plastic surgery that is medically necessary and related to the treatment of a skin-related condition is also included. Removal of excess skin due to weight loss is listed separately under ‘Weight loss surgery’, which is only included in the Gold tier. |
| Breast surgery (medically necessary) (✔✩) | Hospital treatment for the investigation and treatment of breast disorders and associated lymph nodes, and reconstruction/reduction following breast surgery or a preventative mastectomy. For example, breast lesions, breast tumours, asymmetry due to breast cancer surgery and gynecomastia. This clinical category doesn’t pay benefits for cosmetic breast surgery that isn’t medically necessary. |
| Diabetes management (excluding insulin pumps) (✔✩) | Hospital treatment for the investigation and management of diabetes. For example, stabilisation of hypo- or hyper-glycaemia and contour problems due to insulin injections. Treatment for diabetes-related conditions is listed separately under each body system affected. For example, treatment for diabetes-related eye conditions is listed separately under ‘Eye’. |
| Heart and vascular system (✔✩) | Hospital treatment for the investigation and treatment of the heart, heart-related conditions and vascular system. For example, heart failure and heart attacks, monitoring of heart conditions, varicose veins and removal of plaque from arterial walls. |
| Lung and chest (✔✩) | Hospital treatment for the investigation and treatment of the lungs, lung-related conditions, mediastinum and chest. For example, lung cancer, respiratory disorders such as asthma, pneumonia and treatment of trauma to the chest. |
| Blood (✔✩) | Hospital treatment for the investigation and treatment of blood and blood-related conditions. For example, blood clotting disorders and bone marrow transplants. |
| Back, neck and spine (✔✩) | Hospital treatment for the investigation and treatment of the back, neck and spinal column, including spinal fusion. For example, sciatica, prolapsed or herniated disc, spinal disc replacement and spine curvature disorders such as scoliosis, kyphosis and lordosis. |
| Plastic and reconstructive surgery (medically necessary) (✔✩) | Hospital treatment which is medically necessary for the investigation and treatment of any physical deformity, whether congenital or the result of illness or accident. For example, burns requiring a graft, cleft palate, club foot and angioma. Plastic surgery that is medically necessary relating to the treatment of a skin-related condition is listed separately under ‘Skin’. |
| Dental surgery (✔✩) | Hospital treatment for surgery to the teeth and gums. For example, surgery to remove wisdom teeth and dental implant surgery. |
| Podiatric surgery (provided by a registered podiatric surgeon) (✔✩) | Hospital treatment for the investigation and treatment of conditions affecting the foot and ankle, provided by a registered podiatric surgeon. Limited to cover for accommodation and the cost of a prosthesis as listed in the prostheses list of the Private Health Insurance (Prostheses) Rules. Insurers aren’t required to pay for any other hospital treatment benefits for this clinical category but may choose to do so. |
| Implantation of hearing devices (✔✩) | Hospital treatment to correct hearing loss, including implantation of a prosthetic hearing device. Stapedectomy is listed separately under ‘Ear, nose and throat’. |
|
✔ = This clinical category is covered. R = You may only be covered for restricted services^ and treatments under these clinical categories. ✩ = These clinical categories are a minimum requirement of the Silver tier. Source: Privatehealth.gov.au – Clinical categories and product tiers. Updated January 2024. |
|
What’s a Silver Plus policy and what does it cover?
A Silver Plus health insurance policy includes everything under the Silver tier and one or more hospital treatments from the Gold tier.
If a health fund offers a Silver Plus policy, they must provide unrestricted* cover for the additional treatments or categories. Because of its additional coverage, a Silver Plus policy may cost more than a standard Silver policy.
What’s not covered by Silver health insurance?
A standard Silver health insurance policy will have exclusions for all of the hospital treatments in the Gold tier. This means your standard Silver tier policy won’t include:
- Pregnancy and birth
- Pain management with device
- Cataracts
- Joint replacements
- Assisted reproductive services
- Sleep studies
- Dialysis for chronic kidney failure
- Weight loss surgery
- Insulin pumps.
Although this isn’t required, health funds may still include additional cover for one or more of these clinical categories under a Silver+ or Plus health insurance policy.
Choosing your tier
How does Silver hospital cover compare to the other tiers?
Silver is the second-highest level of hospital cover available out of the four tiers, which means it has more benefits than Basic and Bronze but isn’t as comprehensive as Gold. While pricing can differ, a Silver tiered policy will usually cost somewhere between Bronze and Gold.
While it doesn’t include all clinical categories like Gold policies, Silver still covers a wide range of hospital treatments.
Silver tier policies will, at a minimum, include eight more clinical categories than the Bronze tier, totalling 26 clinical categories. In addition to this, Silver hospital policies must include restricted^ cover for in-hospital psychiatric services, in-hospital rehabilitation and palliative care.
Standard Silver tier policies include 12 fewer clinical categories than Gold, which means you may not be covered for premium treatments like insulin pumps or joint replacements. However, you may still be able to get cover for one of these treatments through a Silver Plus policy, which could be a more cost-effective option than getting Gold health insurance.
Silver health insurance policies can also include restricted^ or unrestricted* hospital cover for rehabilitation, hospital psychiatric services and palliative care, unlike the Gold tier, which must offer these services on an unrestricted* basis.
Who might suit Silver tier cover?
Silver health insurance will cover you for a range of hospital treatments, but the tier that suits you most will depend on your situation. To put this into perspective, a standard Silver hospital policy might suit you in the following circumstances:
- Your health is a priority, and you would like cover for a wide range of hospital treatments.
- You aren’t planning on having joint replacement surgery, weight loss surgery or children any time soon and so won’t be needing cover for premium hospital services included under Gold cover. These services may have up to a 12-month waiting period, so it’s important to add these services before you are likely to need them.
- You have a family history of heart problems. The Silver tier will include benefits for treating heart-related conditions (such as heart failure and heart attacks) and monitoring heart conditions.
- You have concerns around your lungs, chest or blood.
- You need a hearing device implanted.
- You have foot issues and could potentially require surgery by a podiatric surgeon.
- You have an active lifestyle or physical job and run the risk of hurting your back, neck or spine.
- You need medically necessary plastic or reconstructive surgery after being physically injured.
Is Silver health insurance worth it?
A Silver health insurance plan may be worth it if it’s within your budget and you may make use of the treatments included under this tier.
However, if you’re comfortable only being covered for a small range of treatments, a lower-level policy like Basic or Bronze might be better suited to your needs.
Also, if you’re planning on having a baby or getting a joint replacement in the near future and want health insurance, you might want to consider a Gold or suitable Silver Plus policy.
How much does Silver health insurance cost?
Silver health insurance will typically cost more than Bronze and less than Gold, but can still vary in price. How much Silver health insurance costs may depend on which health fund provides the policy, what’s included in the policy and other factors that affect your premiums, such as Lifetime Health Cover loading, an Aged Based Discount (depending on your age and eligibility when you took out the policy) and the Australian Government Rebate.
A Silver Plus health insurance policy will generally cost more than regular Silver health insurance, as it will include cover for more hospital treatments. However, a simple way to find out how much Silver health insurance may cost you is to compare health insurance policies online.
Can I get a Silver extras health insurance policy?
Extras cover products aren’t classified under different tiers, as these classifications only apply to hospital products. This also means extras-only policies in Australia can no longer include the name of any metal, gemstone or semi-precious stone in their product name (e.g. Diamond or Platinum extras are no longer allowed).
However, a full range of extras policies are still available, including mid- and higher-level extras products. Also, some combined policies (hospital and extras) may be named Silver hospital and extras.
Meet our health insurance expert, Steven Spicer
As the Executive General Manager of Health, Life and Energy, Steven Spicer is a strong believer in the benefits of private cover and knows just how valuable the peace of mind that comes with cover can be. He is passionate about demystifying the health insurance industry and advocates for the benefits of comparison when it comes to saving money on your premiums.
Want to know more about health insurance?
^Restricted cover – this means your insurer will only pay part of any private hospital costs in that category. You might have to pay large out-of-pocket costs.
*Unrestricted cover – this means your insurer is likely to have an agreement with a hospital. You might not have to pay any out-of-pocket costs other than any agreed excess or co-payments.
1 Privatehealth.gov.au – Clinical categories and product tiers. Updated January 2024.