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Scratching your head over these new policies? Are you tossing up whether or not you need Gold health insurance?

We break down everything you need to know about Gold health insurance.

But first, why do these new tiers exist?

In 2019, the Australian Government introduced Private Health Insurance Reforms to simplify health insurance. Because of these government reforms, all hospital policies are being categorised under four distinctive tiers: Gold, Silver, Bronze and Basic health insurance.

Each tier is categorised based on how many hospital treatments and services it covers, which are listed under respective clinical categories.

These new health insurance tiers began to roll out from 1 April 2019 officially, and all health funds are required to have their products updated and categorised into the health insurance tiers by 1 April 2020.

So, let’s take a look at what constitutes a Gold health insurance tier policy, and why you might consider taking out a gold plan health cover.

What is Gold health insurance?

The Gold tier offers the highest level of cover available under the new government reforms; it’s essentially the new ‘comprehensive’ or ‘top’ level of health insurance, which covers all 38 clinical categories.

So, if you’re looking for the ultimate cover in the Gold tier, you’re not alone!

Over three quarters (77%) of Australians are likely to choose a Gold tier policy due to concerns that Silver health insurance or Bronze health insurance won’t meet their current needs, according to an independent survey.1 Let’s take a look at how the different health insurance tiers differ.

How does Gold health insurance compare to Silver and Bronze?

Gold health insurance covers all 38 clinical categories for hospital services and treatment, which is nine more than what’s covered by Silver health insurance policies and 17 more clinical categories than Bronze health insurance policies.

What’s more, Gold level health insurance policies must include total and unrestricted* cover for all categories (within the outlined scope of cover).

Gold policies also include unrestricted cover for rehabilitation, hospital psychiatric services and palliative care, all of which may either be offered on a restricted^ or unrestricted* basis under lower level Silver, Bronze or Basic tiers.

Due to the Gold tier’s extensive coverage of hospital treatments and services, this top-level cover will generally be more expensive than Silver, Bronze or Basic health insurance policies.

What does Gold health insurance cover?

Gold health insurance policies will include total unrestricted* cover for all hospital treatments (within the scope of cover outlined by the Department of Health) listed under all 38 clinical categories in the Gold tier, as seen below.

Which hospital procedures are covered by Gold health insurance?
Your Gold tier policy provides cover for:            
RehabilitationHospital 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 servicesHospital 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 careHospital 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 systemHospital 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)Hospital 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’, which is only covered in the Gold tier of hospital cover.
Ear, nose & throatHospital 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 grommetsHospital treatment of the tonsils, adenoids and insertion or removal of grommets.
Bone, joint and muscleHospital 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 reconstructionsHospital treatment for surgery for joint reconstructions. For example: torn tendons, rotator cuff tears and damaged ligaments. Joint replacement surgery is listed separately under ‘Joint Replacements’, which is only covered in the Gold tier.
Kidney and bladderHospital 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’, which is only covered in the Gold tier.
Male reproductive systemHospital treatment for the investigation and treatment of the male reproductive system including the prostate.
Digestive systemHospital 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 appendixHospital treatment for the investigation and treatment of a hernia or appendicitis. Digestive conditions are listed separately under ‘Digestive system’.
Gastrointestinal endoscopyHospital 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’.
GynaecologyHospital 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 pregnancyHospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy.
Chemotherapy, radiotherapy and immunotherapy for cancerHospital 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 managementHospital 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’, which is only covered in the Gold tier.
SkinHospital treatment for the investigation and treatment of skin, skin-related conditions and nails. For example: melanoma, minor wound repair and abscesses. 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. Removal of excess skin due to weight loss is listed separately under ‘Weight loss surgery’, which is only covered in the Gold tier.
Breast surgery (medically necessary)Hospital 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)Hospital 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’.
Heart and vascular systemHospital 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 chestHospital 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.
BloodHospital treatment for the investigation and treatment of blood and blood-related conditions. For example: blood clotting disorders and bone marrow transplants.
Back, neck and spineHospital 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)Hospital 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 surgeryHospital 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)Hospital 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 devicesHospital treatment to correct hearing loss, including implantation of a prosthetic hearing device. Stapedectomy is listed separately under ‘Ear, nose and throat’.
CataractsHospital treatment for surgery to remove a cataract and replace with an artificial lens.✔✩
Joint replacementsHospital 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 failureHospital treatment for dialysis treatment for chronic kidney failure. For example: peritoneal dialysis and haemodialysis.✔✩
Pregnancy and birthHospital 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 servicesHospital 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 surgeryHospital 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 pumpsHospital treatment for the provision and replacement of insulin pumps for treatment of diabetes.✔✩
Pain management with deviceHospital 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 (eg. An infusion pump or neurostimulator).✔✩
Sleep studiesHospital treatment for the investigation of sleep patterns and anomalies. For example: sleep apnoea and snoring.✔✩
✔ = This clinical category is covered.
✩ = These clinical categories are a minimum requirement of the Bronze tier only; they’re not required to be covered under the Basic tier.

Source: Department of Health – Clinical and Product Categories Tables for Hospital Treatment Product Tiers (accurate as of July, 2019)

Older woman clutching knee in pain wondering if she’s covered by gold health insurance

Who might suit Gold tier cover?

Whether or not a Gold plan is suitable will depend on your situation. As a guide, the gold level of cover might be worth considering if one or more of the following apply to you:

  • you want the ultimate peace of mind, as Gold health insurance covers all 38 clinical categories.
  • gold health insurance is within your budget, and you will benefit from its added coverage.
  • you’re planning on becoming pregnant and want to be covered to have your baby as a private patient in a private hospital, with the option to potentially choose your obstetrician and be by yourself in a private room if one’s available.
  • you’re considering in-hospital IVF treatment (provided your IVF treatment is deemed medically necessary).
  • you have a family history of bad knees or joints, have a physically hard job, play sport at a high level, or if you’ve previously had a physical accident and may require joint replacement surgery in the future.
  • you have chronic pain and need devices to keep your pain under control or have chronic kidney failure and require dialysis.
  • you struggle with your weight or sleeping patterns and require medically necessary treatment.
  • you have diabetes and require an insulin pump.
  • you need in-hospital treatment for cataracts.

Is Gold the top health insurance available?

If you’re wondering whether Gold health insurance covers everything, it covers all 38 clinical categories outlined by the Department of Health and the Government reforms. So, in terms of how many clinical categories and hospital treatments are covered, Gold would be considered the top health insurance for hospital cover.

However, this doesn’t necessarily mean it’s the right option for you – this will depend on your circumstances.

Is Gold tier health insurance worth it?

Gold health insurance may be worth it if you’ll benefit from the added coverage (i.e. pregnancy and birth, joint replacements and more).

However, if a Gold plan is outside your budget, and you don’t need cover for the other nine clinical categories (e.g. if you’re a male and don’t require cover for ‘pregnancy and birth’), a Gold tier policy may not be the best health insurance for you.

In this case, a Silver Plus or Bronze Plus policy could be worth it, as you may be able to get coverage for some of the treatments found under Gold and it should be more affordable than Gold.

For example, if you want to be covered to have a baby in a private hospital or would like to be covered for a knee replacement in the future, you may be able to find a Silver Plus policy which includes cover for ‘pregnancy and birth’ or ‘joint replacements’ or both.

Can I get a Gold Plus policy?

No, you cannot purchase Gold Plus health insurance. Gold is the highest tier, which means it already covers all clinical categories.

You can only get ‘plus’ policies on Silver, Bronze or Basic. These ‘plus’ policies may offer cover for treatments that are usually only available in higher-level tiers, although this will likely cost extra in premiums.

Can I get a Gold ‘extras-only’ health insurance policy?

No, you can only get gold hospital insurance policies. Under the new government reforms, these classifications only apply to hospital products. Also, extras-only policies can no longer include the name of any metal, gemstone or semi-precious stone in their product name (i.e. Diamond or Platinum extras is no longer allowed).

However, a full range of extras policies is still available, including top-level extras products. Also, some combined policies (hospital and extras) may be named Gold hospital and extras.

How much is Gold health insurance?

The cost of Gold health insurance will generally be more expensive than Silver or Bronze health insurance but will range in price. How much your Gold health cover costs will depend on what your policy includes and which health fund you take out your health insurance policy through.

Want to see how a Gold policy compares to the other tiers? Find out more about Silver, Bronze and Basic policies.


Glossary

^Restricted cover – this means your insurer will pay part of any private hospital costs against that category. You might have to pay large out of pocket costs.2

*Unrestricted cover – this means your insurer is likely to have an agreement with a hospital. You might not have to pay any out of pocket costs other than any agreed excess or co-payments.3

Sources
  1. According to an independent, nationally representative survey which was commissioned by us, Compare the Market, and conducted by Pureprofile in 2018.
  2. Department of Health – Hospital cover product tiers and clinical categories: How product tiers work. (last updated 23 December 2019)
  3. Ibid.

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