Private health insurance tiers explained

The four tiers are Basic, Bronze, Silver and Gold health insurance, each including a different number of compulsory clinical categories and hospital treatments. At a minimum, each tier of hospital insurance must cover:

• Basic tier = 3 restricted clinical categories
• Bronze tier = 18 clinical categories and 3 restricted clinical categories
• Silver tier = 26 clinical categories and 3 restricted clinical categories
• Gold tier = 38 clinical categories.

Health funds can also offer policies that include more clinical categories than required by the standard health insurance tiers. If they do so, these policies may include a ‘+’ or ‘Plus’ in the name and fall under one of three subset health insurance tiers: Basic+, Bronze+ and Silver+.

The basic tier of hospital cover is the lowest level of hospital cover a health fund can offer. The minimum requirement for this level of cover includes treatment in the below clinical categories, offered on a restricted* basis:

• Rehabilitation
• Hospital psychiatric services
• Palliative care.

Want to learn more? Read about the benefits of Basic health insurance policies.

A Bronze hospital insurance policy includes the same restricted benefits as the Basic tier as well as unrestricted** hospital cover for an additional 18 treatments and services (providing some level of cover for 21 clinical categories in total).

(R) = services that must be included on a restricted* basis at a minimum. Funds may choose to offer these on an unrestricted** basis also.

Are you considering this type of policy? We explain more about Bronze health insurance policies here.

A Silver hospital insurance policy includes the same hospital treatments as Bronze policies. Silver health insurance also covers eight additional clinical categories on an unrestricted** basis, providing some level of cover for 29 clinical categories in total.

(R) = services that must be included on a restricted* basis at a minimum. Funds may choose to offer these on an unrestricted** basis also.

Who may find this type of cover suitable? Read more about Silver health insurance policies.

As the highest level of hospital cover, Gold hospital insurance policies must include unrestricted** cover for all clinical categories (38 clinical categories in total). Because it’s the highest level of cover, there is no ‘Plus’ policy option.

All clinical categories must be unrestricted** on Gold hospital cover.

These top-tier policies may be a good choice for those who want complete peace of mind knowing that all clinical categories are included on an unrestricted** basis up to the Medicare Benefits Schedule (MBS) of fees.

Is this type of cover right for you? Learn more about Gold health insurance policies.

Yes, the higher the tier, the more you’ll likely pay. So, Gold tier health insurance typically costs more than the Basic, Bronze, or Silver tiers because Gold includes the most hospital treatments.

However, your health insurance premiums will also depend on several other factors, including your eligibility for an aged based discount, the Lifetime Health Cover loading and your private health insurance rebate tier according to your income level.

No, the Australian Government’s private health insurance rebate is income tested, meaning that your rebate entitlement depends on the taxable income tier you fall under. Paying for a higher hospital tier 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 (dollar value) on a pricier policy.

The rebate applies to hospital, general treatment (extras) and ambulance cover policies, although it doesn’t apply to overseas visitor health cover. For those on a single-parent or family policy, you’ll be income tested using the family income threshold. This threshold is increased by $1,500 for each dependent child after your firstborn.

You can claim your rebate amount as a reduction of your private health insurance premiums or as a tax offset when you lodge your annual tax return. For more information on the private health insurance rebate, refer to the Australian Taxation Office (ATO) website.

The clinical categories that are included on 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):

• Monthly premium (before rebates, discounts or the Lifetime Health Cover loading)
• Clinical categories included
• Waiting periods to be served before you can claim on eligible treatments
• Treatments and services excluded or restricted* from the cover
• Excess and/or co-payment (a payment owed when you claim on your insurance)
• Other policy features (e.g. cover for travel and accommodation for medical purposes)

Should you have complications during your planned surgery and require additional unplanned treatment, you may still be covered even if the further treatment isn’t included under your health insurance policy. We recommend speaking to your health fund prior to any hospital admissions to understand what will be covered and any out-of-pocket expenses that you may incur.

However, if you’re getting a specific hospital treatment and elect to have another one at the same time (which isn’t included under your health insurance policy), 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 or select Basic+ and Bronze+ policies.

* Restricted cover: Refers to being covered only as a private patient in a public hospital. If you go into a private hospital as a private patient, your health fund will not pay anything towards the theatre fees and only a small amount towards your accommodation fee. This means you will face considerable out-of-pocket costs.

** Unrestricted cover: Refers to being covered for your theatre and accommodation fees as a private patient in a private hospital or a private day hospital facility, as well as being covered up to the Medicare Schedule of Fees (MBS) for clinical categories included as unrestricted on your policy. Having this level of cover allows you to choose the available doctor who treats you, provided your doctor has an arrangement with the hospital you want to be treated at, and the hospital you have chosen has beds available.

N.B. The information presented on this page is based on the Australian Government Private health insurance reforms fact sheet.