The clinical categories are new titles of hospital treatment groupings used by all health insurance policies. Clinical categories define what claimable hospital treatments and services each policy includes.
There are 38 clinical categories in total. Gold tier policies cover all these categories, while Basic health insurance policies cover the least.
Clinical categories make it easier to know exactly what your policy covers.
Previously, for example, pregnancy cover could be categorised under any term the health fund chose. Also, the specifics of what pregnancy cover included were dependent on the policy and health fund. Some health funds included cover for birth-related services but excluded cover towards neo-natal care (treatment and care of newborns). This would confuse people and lead them to misunderstand what they were covered for.
Now, health funds must use one set category name for each predetermined set of covered treatments – in this example, all policies will classify treatment related to the birth of a baby as ‘pregnancy and birth’.
Yes, the higher the tier, the more you’ll likely pay. Gold tier health insurance typically costs more than Silver, Bronze or Basic tiers because Gold covers the most hospital treatments.
However, this may differ with ‘plus’ policies. For example, If your health insurer offers a bronze plus product that covers dental surgery, you may pay more than a standard bronze tiered product with that insurer but less than the cost of a silver policy that could cover more than you need.
Your health insurance premiums will also depend on several factors, including the Medicare Levy Surcharge, Lifetime Health Cover loading and your income tier according to the private health insurance rebate.
The clinical categories that are covered under a policy will be detailed in your policy documentation and the Private Health Information Statement (PHIS). The PHIS breaks down the following information (among other things):
If you’re admitted for a planned hospital treatment listed on your hospital insurance policy, you will be covered for that procedure. Should you have complications during your intended surgery and you require additional unplanned treatment, you may still be covered – even if the further treatment isn’t covered under your health insurance tier.
However, if you’re getting a specific hospital treatment and elect to have another one at the same time (which isn’t covered under your health insurance tier), your health fund doesn’t have to cover this additional treatment.
For example, say you have Bronze health insurance and plan on removing your tonsils, but also elect to have dental surgery while you’re in hospital. In this case, your health fund is unlikely to cover your elective dental treatment, as dental surgery is only covered under Silver health insurance policies.
Insurers may offer policies that include additional cover on top of the minimum requirements for each category tier; these are then appended with a + or the word ‘plus’. Your health fund isn’t obligated to include additional cover. However, if they do, it must be unrestricted2 unless it’s a Basic tiered policy, in which case it can be included on a restricted1 or unrestricted2 level of cover.
Be sure to read through your policy brochure to get an understanding of what is and isn’t covered and whether any limits apply.
No, the Australian Government’s private health insurance rebate is income tested, meaning that your rebate entitlement depends on the income tier you fall under. Paying for a higher tier of cover won’t prevent you from crossing the income threshold into the next income tier. However, because the premium reduction is percentage-based, you will technically receive a higher rebate on a pricier policy.
Australians are often confused as to exactly what their private health insurance policy covers. However, these health insurance categories and tiers can reduce this confusion and make it easier to understand what hospital treatments they are and aren’t covered for.
With these health insurance tiers, you can easily review your cover and shop around for health insurance policies that best meet your healthcare needs.
N.B. The information presented on this page is based on the Private Health Insurance (Reforms) Amendment Rules 2018.