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Hospital insurance has never been easier to shop around for. Health insurance tiers allow you to compare health funds on equal footing, policy for policy.

What are the health insurance tiers all about?

As outlined by the Australian Government’s private health insurance reforms, hospital insurance policies are now categorised into different tiers. The reforms require that all hospital treatments covered by health insurance are listed under the same standard term, called a clinical category. Each tier covers a specific set of clinical categories, so it’s easier to understand exactly what you’re insured for through your policy.

All hospital products must be categorised into these private health insurance tiers: Gold, Silver, Bronze and Basic. These health insurance tiers only apply to hospital policies; they do not apply to extras policies (i.e. out-of-hospital services, like dental check-ups).

What are the different levels of health insurance tiers available?

The four tiers are Gold, Silver, Bronze and Basic health insurance, each covering a different number of clinical categories and hospital treatments:

  • Gold tier = 38 clinical categories
  • Silver tier = 29 clinical categories
  • Bronze tier = 21 clinical categories
  • Basic tier = 3 clinical categories.

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

See what each health insurance tier covers below:

What does the Basic health insurance tier cover?

The basic tier of hospital cover is the lowest level of hospital cover a health fund can offer under the legislation. The minimum requirement for this level of cover includes treatment in the below clinical categories, offered on a restricted1 basis:

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

Want to learn more? Read about who could benefit from Basic health insurance policies.

What does Bronze health insurance cover?

A Bronze health insurance policy covers the same benefits as the basic tier and provides unrestricted hospital cover for an additional 18 treatments and services (covering 21 clinical categories in total).2

Minimum requirements for Bronze hospital cover
Features which may be either restricted1 or unrestricted2
RehabilitationHospital psychiatric servicesPalliative care
Features which must be unrestricted2
Brain and nervous systemEye (not cataracts)Ear, nose and throat
Tonsils, adenoids and grommetsBone, joint and muscleJoint reconstructions
Kidney and bladderMale reproductive systemDigestive system
Hernia and 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

Are you considering this type of policy? We’re happy to explain more about who might benefit from Bronze health insurance policies.

What does Silver health insurance cover?

A Silver health insurance policy covers the same hospital treatments found in Basic and Bronze policies. Silver health insurance also covers eight additional clinical categories on an unrestricted basis (covering 29 clinical categories in total).2

Minimum requirements for Silver hospital cover
Features which may be either restricted1 or unrestricted2
RehabilitationHospital psychiatric servicesPalliative care
Features which must be unrestricted2
Brain and nervous systemEye (not cataracts)Ear, nose and throat
Tonsils, adenoids and grommetsBone, joint and muscleJoint reconstructions
Kidney and bladderMale reproductive systemDigestive system
Hernia and 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

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

What does Gold health insurance cover?

As the highest level of hospital cover, Gold health 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.

Minimum requirements for Gold hospital cover (unrestricted2 features)
RehabilitationHospital psychiatric servicesPalliative care
Brain and nervous systemEye (not cataracts)Ear, nose and throat
Tonsils, adenoids and grommetsBone, joint and muscleJoint reconstructions
Kidney and bladderMale reproductive systemDigestive system
Hernia and 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 may be the best choice for those who want complete peace of mind and unrestricted2 cover for the full range of features included under all the clinical categories, up to the Medicare Benefits Schedule (MBS) of fees.

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

Frequently asked questions

What are 'clinical categories'?

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’.

Are the health insurance tiers priced accordingly?

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 SurchargeLifetime Health Cover loading and your income tier according to the private health insurance rebate.

Where can I find out what my policy covers?

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):

  • Monthly premium (minus rebates or Lifetime Health Cover 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 policy features (e.g. cover for travel and accommodation).

What if I have complications during surgery and need treatment not included in my health insurance tier?

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.

What dies it mean if my policy has a 'plus' or '+' in the name?

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.

Will my health insurance tier affect my Australian government rebate?

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.

How can health insurance tiers benefit you?

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.

Is your new tier the right product for you?

If you already had health insurance before the private health insurance reforms, your policy will have changed to align with these new tiers. As such, you may have lost features you enjoyed previously, or worse – you may be paying for cover you don’t need.

That’s why it’s always the right time to review your health insurance against other policies to make sure your hospital insurance covers everything you need and that you’re not overpaying.

Glossary of terms

  • Restricted cover: Refers to being covered only as a private patient in a public hospital. However, 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 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 Private Health Insurance (Reforms) Amendment Rules 2018.

Anthony Fleming, General Manager

Top tips from our health insurance expert, Anthony Fleming

  1. Private health insurers aren’t required to stick to the minimum hospital inclusions, they can offer more coverage through ‘plus products’. This could allow you to find coverage that suits your needs without needing to pay additional premiums for higher tier coverage.
  2. Whilst plus products can provide additional value, having this flexibility means a lot of variation can occur between the health funds when it comes to what’s included and excluded, so ensure you are aware of what you are covered for when choosing a plus policy.
  3. When comparing health insurance, ensure that you check all the relevant product brochures prior to making a purchasing decision.

Sources

  1. Department of Health – Private Health Insurance Reforms: Gold/Silver/Bronze/Basic product tiers
  2. Private Health Insurance (Reforms) Amendment Rules 2018, Australian Government, Federal Register of Legislation

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