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Hospital insurance has never been easier to shop around for – you just don’t know it yet.

What are the health insurance tiers all about?

As outlined by the Federal Government’s private health insurance reforms, hospital insurance policies must now be categorised into different health insurance tiers in Australia. Each tier has to cover a minimum number of treatments and services, so it’s easier to see exactly what you’re insured for through your policy.

Also, hospital treatments will each be listed under the same standard term, called clinical categories.

All hospital products must be categorised into these private health insurance tiers by 1 April 2020. Gold, Silver, Bronze and Basic health insurance tiers only apply to hospital policies; tiers don’t 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 – from highest to lowest – are Gold, Silver, Bronze and Basic health insurance. Gold tier policies cover a wider range of hospital treatments and services (38 clinical categories). Lower tiers cover fewer hospital treatments (i.e. 29 clinical categories with Silver, 21 with Bronze).

Health funds can also offer policies that cover more treatments than required in the standard health insurance tiers. If they do so, these policies include ‘+’ 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 Basic health insurance tier cover?

Basic 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

However, under a Basic hospital policy, health funds 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 are called ’Basic Plus‘ or ’Basic +’ policies.

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 has the same minimum requirement as Basic to include restricted1 hospital cover for Rehabilitation, Hospital psychiatric services and Palliative care. Bronze health insurance also provides unrestricted2 cover for an additional 18 treatments and services than Basic health insurance (covering 21 clinical categories in total).

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 & 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 features that cover other clinical categories, which are typically only cover in higher health insurance tiers, like Silver or Gold. If additional cover is included, health funds must offer the cover at an unrestricted2 level, and they must include ’Bronze +’ or ’Bronze Plus‘ in the name of the policy.

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, at minimum, covers the same hospital treatments found in Basic and Bronze policies. Silver health insurance also covers eight more clinical categories than Bronze health insurance on an unrestricted2 basis (covering 29 clinical categories in total).

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 & 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 usually only found in Gold cover. However, if they do so, the cover provided must be unrestricted2. Should they choose to include additional features on top of the minimum requirements, they must include ‘+’ or ‘plus’ in the policy’s name (e.g. Silver plus).

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

What does Gold health insurance cover?

For the ultimate hospital cover, Gold health insurance policies must include unrestricted2 cover for all clinical categories that are covered under Basic, Bronze, and Silver. Gold health insurance also includes unrestricted2 hospital cover for treatments found under nine more clinical categories than Silver health insurance (38 clinical categories in total).

Minimum requirements for Gold hospital cover (unrestricted2 features)
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 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.

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 the clinical 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: Pregnancy, Birth-Related Services, Pregnancy and Birth-Related Services or Obstetrics.

Also, in terms of what pregnancy cover included, it depended 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), for example.

Now, health funds must use one set category name for each feature – 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 more hospital treatments.

However, this may differ with plus policies. For example, if your health fund includes Pregnancy and Birth in your Bronze plus policy, it may end up costing more than a standard Silver health insurance policy (which doesn’t include cover for ‘pregnancy and birth’).

How can the 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’re covered for (or not covered for).

With these health insurance tiers, you can easily review your cover and shop around for health insurance policies that cover the hospital treatments you require.

Frequently asked questions

Where can I find out exactly what my policy covers?

The clinical categories that are and are not covered under a policy will be detailed in the Private Health Information Statement (PHIS), which replaces your current Standard Information Statement (SIS). The PHIS breaks 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 restricted1from the cover
  • Excess (i.e. a payment owed when you claim on your insurance)
  • Other policy features (e.g. travel and accommodation)

Source: Health.gov.au

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

If you’re admitted for planned hospital treatment that is listed on your hospital insurance policy, you will be covered for that procedure. If you have complications during your intended surgery and you require additional unplanned treatment, this will also be covered – even if the further treatment is for a condition which isn’t covered under your health insurance tier.

However, if you’re going in for 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 the 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 does 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 are 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.

What’s covered will vary based on your health fund, and the level of extras cover you take out. Be sure to read through your policy brochure to get an understanding of what is and isn’t covered and whether any limits apply.

Is your new tier the right product for you?

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

That’s why now is the perfect 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 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.
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

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

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