A change is coming that will make it easier to shop around for health insurance.

Among a series of Federal Government reforms, private hospital insurance products will be split into four different category tiers: BasicBronzeSilver and Gold.

This will mean that all hospital products will start to be categorised into these tiers from 1 April 2019, although, health funds can (and might) make the changes earlier than this date. All health funds will have to update their entire product suite in line with these rules by 1 April 2020.

N.B. The information presented on this page is based on the Private Health Insurance (Reforms) Amendment Rules 2018.

What are the new Australian health insurance categories?

Woman with a gynaecologist covered by health insurance

The private health insurance category tiers are a simplified way to review different levels of hospital cover. The four categories are Basic, Bronze, Silver and Gold. Gold policies will cover a wider range of services (38 clinical categories); but the further down the tiers you go, the less you’re covered for (i.e. 29 with Silver, 21 with Bronze).

How will the health insurance categories work?

In conjunction with the new tiers, clinical categories will also be introduced, meaning that health funds will have to use the same categories to define what benefits (i.e. treatments and services you can claim on) are included on their policies.

For example, currently when treatment related to the birth of a baby is included or excluded on a policy, the funds can use any term they wish, whether it be Pregnancy, Birth Related Services, Pregnancy and Birth Related Services or Obstetrics. Some even include cover for Birth Related Services but exclude cover towards Neo-Natal Care (treatment and care of newborns).

The result? Customers are left confused and not knowing the difference between the categories. The new reforms will reduce this confusion, by having one set category that the funds must use for each benefit – in this example, treatment related to the birth of a baby will be classified in all policies as “Pregnancy and birth”.

The new tiers of Gold, Silver, Bronze and Basic will not apply to extras policies (i.e. out of hospital services);

Each tier will have minimum required coverage for the standard clinical categories list of hospital treatments, which can be seen in the table below. Funds will have to include the name of the product tier that the policy falls under in the names of their policies, and if they choose to include benefits above and beyond the set of minimum required coverage, the name of the policy will also include “+” or “plus”.

Want to read more about each tier? Skip to the end of the table.

Hospital treatments by clinical categoryBasicBronzeSilverGoldExamples of covered hospital investigation and treatment:
RehabilitationRRRHospital treatment for physical rehabilitation for a patient related to surgery or illness. For example: inpatient and admitted day patient rehabilitation, stroke recovery, cardiac rehabilitation.
Hospital psychiatric servicesRRRHospital 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 careRRRHospital treatment for care where the intent is primarily providing quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain.
Brain and nervous systemRCPHospital treatment for the investigation and treatment of the brain, brain-related conditions, spinal cord and peripheral nervous system. For example: stroke, brain or spinal cord tumours, head injuries, epilepsy and Parkinson’s disease.
Eye (not cataracts)RCPHospital 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.
Ear, nose and throatRCPHospital 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 ear drum, sinus surgery, removal of foreign bodies, stapedectomy and throat cancer.
Tonsils, adenoids and grommetsRCPHospital treatment of the tonsils, adenoids and insertion or removal of grommets.
Bone, joint and muscleRCPHospital 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 reconstructionsRCPHospital treatment for surgery for joint reconstructions. For example: torn tendons, rotator cuff tears and damaged ligaments. Joint replacements are listed separately under Joint replacements.
Kidney and bladderRCPHospital treatment for the investigation and treatment of the kidney, adrenal gland and bladder. For example: kidney stones, adrenal gland tumour and incontinence. Dialysis is listed separately under Dialysis for chronic kidney failure.
Male reproductive systemRCPHospital treatment for the investigation and treatment of the male reproductive system including the prostate. For example: male sterilisation, circumcision and prostate cancer.
Digestive systemRCPHospital 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 appendixRCPHospital treatment for the investigation and treatment of a hernia or appendicitis. Digestive conditions are listed separately under Digestive system.
Gastrointestinal endoscopyRCPHospital treatment for the diagnosis, investigation and treatment of the internal parts of the gastrointestinal system using an endoscope. For example: colonoscopy, gastroscopy, endoscopic retrograde cholangiopancreatography (ERCP). Non-endoscopic procedures for the digestive system are listed separately under Digestive system.
GynaecologyRCPHospital 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 pregnancyRCPHospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy.
Chemotherapy, radiotherapy and immunotherapy for cancerRCPHospital 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 managementRCPHospital treatment for pain management that does not 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 (for example an infusion pump or neurostimulator) is listed separately under Pain management with device.
SkinRCPHospital treatment for the investigation and treatment of skin, skin-related conditions and nails. The removal of foreign bodies is also included. Plastic surgery that is medically necessary and relating to the treatment of a skin-related condition is also included. For example: melanoma, minor wound repair and abscesses. Removal of excess skin due to weight loss is listed separately under Weight loss surgery.
Breast surgery (medically necessary)RCPHospital treatment for the investigation and treatment of breast disorders and associated lymph nodes, and reconstruction and/or 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 does not require benefits to be paid for cosmetic breast surgery that is not medically necessary.
Diabetes management (excluding insulin pumps)RCPHospital treatment for the investigation and management of diabetes. For example: stabilisation of hypo- or hyper- glycaemia, 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. Treatment for ulcers is listed separately under Skin.
Heart and vascular systemRCPHospital treatment for the investigation and treatment of the heart, heart-related conditions and vascular system. For example: heart failure and heart attack, monitoring of heart conditions, varicose veins and removal of plaque from arterial walls.
Lung and chestRCPHospital 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.
BloodRCPHospital treatment for the investigation and treatment of blood and blood-related conditions. For example: blood clotting disorders and bone marrow transplants.
Back, neck and spineRCPHospital 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)RCPHospital treatment which is medically necessary for the investigation and treatment of any physical deformity, whether acquired as a result of illness or accident, or congenital. 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 surgeryRCPHospital 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)RCPHospital treatment for the investigation and treatment of conditions affecting the foot and/or ankle, provided by a registered podiatric surgeon, but limited to cover for accommodation and the cost of a prosthesis as listed in the prostheses list set out in the Private Health Insurance (Prostheses) Rules, as in force from time to time. Note: Insurers are not required to pay for any other benefits for hospital treatment for this clinical category but may choose to do so.
Implantation of hearing devicesRCPHospital treatment to correct hearing loss, including implantation of a prosthetic hearing device. Stapedectomy is listed separately under Ear, nose and throat.
CataractsRCPHospital treatment for surgery to remove a cataract and replace with an artificial lens.
Joint replacementsRCPHospital treatment for surgery for joint replacements, including revisions, resurfacing, partial replacements and removal of prostheses. For example: replacement of shoulder, wrist, finger, hip, knee, ankle or toe joint.
Dialysis for chronic kidney failureRCPHospital treatment for dialysis treatment for chronic kidney failure. For example: peritoneal dialysis and haemodialysis.
Pregnancy and birthRCPHospital treatment for investigation and treatment of conditions associated with pregnancy and child birth. Treatment for the baby is covered under the clinical category relevant to their condition. For example, respiratory conditions are covered under Lung and chest.
Assisted reproductive servicesRCPHospital treatment for fertility treatments or procedures. For example: retrieval of eggs or sperm, In vitro Fertilisation (IVF), and Gamete Intra-fallopian Transfer (GIFT).
Weight loss surgeryRCPHospital treatment for surgery that is designed to reduce a person’s weight, remove excess skin due to weight loss and reversal of a bariatric procedure. For example: gastric banding, gastric bypass, sleeve gastrectomy.
Insulin pumpsRCPHospital treatment for the provision and replacement of insulin pumps for treatment of diabetes.
Pain management with deviceRCPHospital treatment for the implantation, replacement or other surgical management of a device required for the treatment of pain. For example: treatment of nerve pain, back pain, and pain caused by coronary heart disease with a device (for example an infusion pump or neurostimulator).
Sleep studiesRCPHospital treatment for the investigation of sleep patterns and anomalies. For example: sleep apnoea and snoring.
Indicates the clinical category is a minimum requirement of the product tier. The service must be covered on an unrestricted basis.
R – Indicates the clinical category is a minimum requirement of the product tier. The service may be offered on a restricted cover basic in Basic, Bronze and Silver product tiers only.
RCP – Restricted cover permitted: indicates the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional services on a restricted or unrestricted basis.
(Blank) – Indicates the treatment/service is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories; however, it must be on an unrestricted basis.
Source: Private Health Insurance (Reforms) Amendment Rules 2018

Basic hospital cover will be the lowest level of hospital cover a health fund can offer under the new legislation. The minimum requirement for this level of cover includes treatment in the below clinical categories. These categories may be offered on a restricted1 cover basis:

  1. Rehabilitation
  2. Hospital psychiatric services
  3. Palliative care

However, under a basic hospital policy, any health fund can offer any of the additional clinical categories should they choose to do so. These additional categories can either be on restricted1 terms or unrestricted2 terms. Such policies will be called “Basic Plus” or “Basic +” policies.

Want to learn more? Read about basic health insurance policies.

A bronze policy will have the same minimum requirement to include restricted1 cover for Rehabilitation, Hospital psychiatric services and Palliative care, as well as providing unrestricted2 cover for an additional 18 treatments and services (covering 21 clinical categories in total):

Minimum requirements for Bronze hospital cover
Benefits which may be either restricted1 or unrestricted2
RehabilitationHospital psychiatric servicesPalliative care
Benefits which must be unrestricted2
Brain and nervous systemEye (not cataracts)Ear, nose & throat
Tonsils, adenoids and grommetsBone, joint and muscleJoint reconstructions
Kidney and bladderMale reproductive systemDigestive system
Hernia & appendixGastrointestinal endoscopyGynaecology
Miscarriage and termination of pregnancyChemotherapy, radiotherapy and immunotherapy for cancerPain management
SkinBreast surgery (medically necessary)Diabetes management (excluding insulin pumps)

Source: Department of Health – Clinical and Product Categories Tables for Hospital Treatment Product Tiers

Although it isn’t a minimum requirement, health funds may choose to include benefits towards other clinical categories, which are found in higher level of cover tiers like Silver or Gold. If they do, they must offer the cover at an unrestricted2 level and they must include “Bronze +” or “Bronze Plus” in the name of the policy.

Considering this type of policy? We’re happy to explain more about bronze health insurance policies.

A silver policy will, at minimum, include the same hospital treatments found in Basic and Bronze policies, as well as treatments under eight more clinical categories covered on an unrestricted2 basis (covering 29 clinical categories in total).

Minimum requirements for Silver hospital cover
Benefits which may be either restricted1 or unrestricted2
RehabilitationHospital psychiatric servicesPalliative care
Benefits which must be unrestricted2
Brain and nervous systemEye (not cataracts)Ear, nose & throat
Tonsils, adenoids and grommetsBone, joint and muscleJoint reconstructions
Kidney and bladderMale reproductive systemDigestive system
Hernia & appendixGastrointestinal endoscopyGynaecology
Miscarriage and termination of pregnancyChemotherapy, radiotherapy and immunotherapy for cancerPain management
SkinBreast surgery (medically necessary)Diabetes management (excluding insulin pumps)
Heart and vascular systemLung and chestBlood
Back, neck and spinePlastic and reconstructive surgery (medically necessary)Dental surgery (in hospital)
Podiatric surgery (by a registered podiatric surgeon)Implantation of hearing devices

Source: Department of Health – Clinical and Product Categories Tables for Hospital Treatment Product Tiers

Although not a minimum requirement, health funds may choose to offer additional cover for other clinical categories which are found in Gold cover. However, if they do so, the cover provided must be unrestricted2. Should they choose to include additional benefits on top of the minimum requirements, they must include “+” or “plus” in the name of the policy.

Who is this type of cover suitable for? Read about silver health insurance policies.

For the ultimate hospital cover, policies under the Gold category tier must include unrestricted2 cover for all clinical categories that are covered under Basic, Bronze, and Silver, as well as unrestricted2 cover for treatments found under an additional nine clinical categories (38 clinical categories in total).

Minimum requirements for Gold hospital cover (unrestricted2 benefits)
RehabilitationHospital psychiatric servicesPalliative care
Brain and nervous systemEye (not cataracts)Ear, nose & throat
Tonsils, adenoids and grommetsBone, joint and muscleJoint reconstructions
Kidney and bladderMale reproductive systemDigestive system
Hernia & appendixGastrointestinal endoscopyGynaecology
Miscarriage and termination of pregnancyChemotherapy, radiotherapy and immunotherapy for cancerPain management
SkinBreast surgery (medically necessary)Diabetes management (excluding insulin pumps)
Heart and vascular systemLung and chestBlood
Back, neck and spinePlastic and reconstructive surgery (medically necessary)Dental surgery (in hospital)
Podiatric surgery (by a registered podiatric surgeon)Implantation of hearing devicesCataracts
Joint replacementsDialysis for chronic kidney failurePregnancy and birth
Assisted reproductive servicesWeight loss surgeryInsulin pumps
Pain management with deviceSleep studies

Source: Department of Health – Clinical and Product Categories Tables for Hospital Treatment Product Tiers

These top-tier policies are the best choice for those who want complete peace of mind and unrestricted2 cover for the full range benefits included under all the clinical categories, up to the Medicare Benefit Schedule (MBS) of fees.

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

Frequently Asked Questions

Where can I find out exactly what I’m covered for?

Once a policy is updated with the clinical categories and tiers, what is and isn’t covered will be detailed in a Private Health Information Statement (PHIS), which replaces your current Standard Information Statement (SIS). These will be available to consumers and policy-holders alike through privatehealth.gov.au website. The PHIS will break down the following information (among other things):

  • Monthly premium (minus rebates or LHC loading)
  • Clinical categories covered
  • Waiting periods to be served before you can claim on said treatments
  • Treatments and services excluded or restricted1 from the cover
  • Excess (i.e. a payment owed when you claim on your insurance)
  • Other features and benefits (e.g. travel and accommodation benefits)

SourceHealth.gov.au Information Statement Table (PDF)

What if my surgery reveals something I’m not covered for in my category?

If you are admitted for investigative surgery for hospital treatment that is listed on your hospital insurance policy, you will be covered for that procedure and any treatment provided during the operation, even if the investigation shows that you have a condition which isn’t covered under your category tier.

What will it mean if the policy has a ‘plus’ or “+” in the name?

Insurers are able to offer policies that include additional cover on top of the minimum requirements for each category tier: these will be appended with a + or the word Plus. Your health fund isn’t obligated to include additional cover, but if they choose to, it must be unrestricted2, unless it’s a Basic tiered policy, in which case they can choose to include it on a restricted1 or unrestricted2 level of cover.

When will these changes become effective?

Health funds can implement these changes at any time. However, they must all be using the same clinical categories and tiers by 1 April 2020 in order to comply with the new legislation. Don’t stress; your health fund is required to give you notice before making detrimental changes to your policy.

Glossary of terms
  1. Restricted cover – refers to being covered as a private patient in a public hospital. However, if you go into hospital as a private patient in a private hospital, your health fund will not pay any benefits towards the theatre fees and only a small benefit towards your accommodation fee. This means you will face considerable out-of-pocket costs.
  2. 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 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.
Sources
  • Department of Health – Private Health Insurance Reforms: Gold/Silver/Bronze/Basic product tiers
  • Private Health Insurance (Reforms) Amendment Rules 2018, Australian Government, Federal Register of Legislation

So, what are you waiting for?

Compare health insurance
Or call us on 1800 304 709