Gold health insurance policies
A guide to Gold health insurance
Updated 26 March, 2024
Why are there health insurance tiers?
In 2019, the Australian Government introduced Private Health Insurance Reforms to simplify health insurance. Because of these government reforms, all hospital policies are categorised into four distinctive tiers: Basic, Bronze, Silver and Gold.
Each tier is categorised based on hospital treatments and services it includes, which are listed under respective clinical categories.
So, let’s take a look at what constitutes the Gold health insurance tier and why you might consider taking out Gold health cover.
What is Gold health insurance?
The Gold tier offers the highest level of cover available on the health insurance market. It’s essentially the ‘comprehensive’ or ‘top’ level of hospital insurance.
This means that you’ll be covered for all in-hospital procedures listed on the Medicare Benefits Schedule (MBS) as a private patient in either a private or public hospital. When you go in for treatment, your health fund may pay 25% of the MBS fee for your treatment, as well as hospital charges such as accommodation, theatre fees, medicines and dressings. The other 75% of the MBS fee is paid by Medicare. If your treating doctors choose to charge above the MBS fee, you could be responsible for paying the gap, so you may have some out-of-pocket expenses.
Depending on your state of residence, your Gold hospital insurance will often also include cover for ambulance services. For example, QLD residents are covered for ambulance services through their state government, so they don’t need to worry about whether ambulance cover is included in their insurance. However, residents in other states (like NSW) might want to consider a policy that offers ambulance cover, as it’s not covered by their state government.
Expert tips on Gold health insurance
Our health insurance expert, Steven Spicer, knows how important it is to get hospital insurance that works for you and your family, which is why he’s put together these tips on how to choose your hospital policy tier:
Steven Spicer
Executive General Manager – Health, Life & Energy
Cover gives you more choice
Private health insurance gives you the ability to improve the quality of your healthcare options. Having cover allows for more choice and control of when and where you’re treated, and by whom.
Increase your excess for cheaper premiums
While having lower premiums is tempting, cheaper doesn’t necessarily mean better. Instead of sacrificing inclusions on your cover, consider increasing your excess to lower costs.
Know your options
There are many options out there when it comes to private health insurance. This is why speaking to a health insurance specialist can be so important. With the right cover you can have peace of mind knowing you have access to high-quality health care of your choice.
Inclusions and exclusions
What does Gold health insurance cover?
Gold health insurance policies include unrestricted* cover for all medically necessary inpatient hospital treatments (within the scope of cover outlined by the Department of Health) listed under the 38 clinical categories.
| Your Gold tier policy provides cover for: | |
|---|---|
| Rehabilitation | Hospital treatment for physical rehabilitation for a patient related to surgery or illness. For example: inpatient and admitted day patient rehabilitation, stroke recovery and cardiac rehabilitation. |
| Hospital psychiatric services | Hospital 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 care | Hospital treatment for care that provides quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain. |
| Brain and nervous system | Hospital 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 eye trauma. |
| Ear, nose & throat | Hospital 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 eardrums, sinus surgery, removal of foreign bodies, stapedectomy and throat cancer. |
| Tonsils, adenoids and grommets | Hospital treatment of the tonsils, adenoids and insertion or removal of grommets. |
| Bone, joint and muscle | Hospital 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 reconstructions | Hospital treatment for surgery for joint reconstructions. For example: torn tendons, rotator cuff tears and damaged ligaments. |
| Kidney and bladder | Hospital treatment for the investigation and treatment of the kidney, adrenal gland and bladder. For example: kidney stones, adrenal gland tumours and incontinence. |
| Male reproductive system | Hospital treatment for the investigation and treatment of the male reproductive system, including the prostate. |
| Digestive system | Hospital 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 appendix | Hospital treatment for the investigation and treatment of a hernia or appendicitis. |
| Gastrointestinal endoscopy | Hospital treatment for the diagnosis, investigation and treatment of the internal parts of the gastrointestinal system using an endoscope. For example: colonoscopy, gastroscopy and endoscopic retrograde cholangiopancreatography (ERCP). |
| Gynaecology | Hospital 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 pregnancy | Hospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy. |
| Chemotherapy, radiotherapy and immunotherapy for cancer | Hospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours. The surgical treatment of cancer is included under each body system category (e.g. skin cancer surgery is included under the ‘Skin’ clinical category). |
| Pain management | Hospital treatment for pain management that doesn’t 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. |
| Skin | Hospital 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 related to the treatment of a skin-related condition is also included. |
| Breast surgery (medically necessary) | Hospital treatment for the investigation and treatment of breast disorders and associated lymph nodes, and reconstruction 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 doesn’t pay benefits for cosmetic breast surgery that isn’t medically necessary. |
| Diabetes management (excluding insulin pumps) | Hospital treatment for the investigation and management of diabetes. For example: stabilisation of hypo- or hyper-glycaemia and contour problems due to insulin injections. Treatment for diabetes-related conditions is listed separately under each body system affected (e.g. treatment for diabetes-related eye conditions is included under ‘Eye’). |
| Heart and vascular system | Hospital 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 chest | Hospital 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. |
| Blood | Hospital treatment for the investigation and treatment of blood and blood-related conditions. For example: blood clotting disorders and bone marrow transplants. |
| Back, neck and spine | Hospital 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 congenital or caused by illness or accident. For example: burns requiring a graft, cleft palate, club foot and angioma. |
| Dental surgery | Hospital treatment for surgery on 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. This benefit is limited to cover for accommodation and the cost of a prosthesis as listed in the Private Health Insurance (Prostheses) Rules. 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 devices | Hospital treatment to correct hearing loss, including implantation of a prosthetic hearing device. |
| Cataracts | Hospital treatment for surgery to remove a cataract and replace it with an artificial lens. |
| Joint replacements | Hospital treatment for surgery for joint replacements, including revisions, resurfacing, partial replacements and removal of prostheses. For example: replacement of the shoulder, wrist, finger, hip, knee, ankle or toe joint. |
| Dialysis for chronic kidney failure | Hospital treatment for dialysis treatment for chronic kidney failure. For example: peritoneal dialysis and haemodialysis. |
| Pregnancy and birth | Hospital treatment for investigation and treatment of conditions associated with pregnancy and childbirth. |
| Assisted reproductive services | Hospital 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 surgery | Hospital treatment for surgery 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 and sleeve gastrectomy. |
| Insulin pumps | Hospital treatment for the provision and replacement of insulin pumps for the treatment of diabetes. |
| Pain management with device | Hospital 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 (e.g. an infusion pump or neurostimulator). |
| Sleep studies | Hospital treatment for the investigation of sleep patterns and anomalies. For example: sleep apnoea and snoring. |
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Source: Privatehealth.gov.au – Clinical categories and product tiers. Updated January 2024. |
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Are there waiting period on Gold tier policies?
Waiting periods work the same for Gold tiered policies as they do on all hospital insurance policies, as these are regulated by the government. These waiting periods are:
| Service | Waiting period |
|---|---|
| Pre-existing health conditions | 12 months |
| Birth-related services and pregnancy | 12 months |
| Rehabilitation, palliative care and psychiatric care (even for a pre-existing condition) | 2 months |
| All other conditions | 2 months |
A pre-existing condition is any ailment, illness or condition that, in the opinion of a medical practitioner assigned by your health fund, you showed signs or symptoms of six months prior to taking out cover.
When you upgrade to a Gold tier hospital insurance policy, you’ll only need to serve a waiting period for the upgrades to your policy, so you won’t need to re-serve any waiting periods you’ve already completed with your current health fund.
Choosing your tier
Who might suit Gold tier cover?
Whether or not a Gold plan is suitable for you will depend on your situation. As a guide, you might want to consider upgrading to this level of cover if one or more of the following apply to you:
- You want peace of mind, as Gold health insurance includes all 38 clinical categories.
- Gold health insurance is within your budget, and you will benefit from its extensive coverage.
- You’re planning on becoming pregnant and want to be able to claim a benefit for having your baby as a private patient in a private hospital, with the option to potentially choose your available obstetrician and have a private room (if one’s available).
- You’re considering in-hospital IVF treatment (provided your IVF treatment is deemed medically necessary).
- You may require joint replacement surgery in the future if, for example, you have a family history of bad knees or joints, have a physically hard job, play sport at a high level or you’ve previously had a physical accident.
- 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.
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 still vary in price. The cost of your Gold health cover will depend on what your policy includes and which health fund you take out your insurance policy through.
You’ll also want to consider the effect of the Australian Government Rebate, Lifetime Health Cover loading, Medicare Levy Surcharge and age-based discount on your total premiums before taking out a policy.
How does Gold health insurance compare to Silver and Bronze?
Gold health insurance includes all 38 clinical categories for hospital services and treatment, which is 9 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 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.
Is Gold the top health insurance available?
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. Health funds can also offer ‘Plus’ or ‘+’ tiered policies, which include some of the categories of a higher-level tier but not enough to enter that tier. It is therefore important to compare the different options available.
There is a lot to consider, such as inclusions, restrictions, exclusions and premiums. The right cover for you will depend on your budget and healthcare needs, so we recommend shopping around to find a policy that works for you.
Can I get a Gold Plus policy?
No, you cannot purchase Gold Plus health insurance. Gold is the highest tier, which means it already includes all clinical categories.
You can only get ‘plus’ policies in Silver, Bronze or Basic tiers. 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 health insurance policy?
No, you can only get Gold hospital insurance policies. Under the 2019 government reforms, these classifications only apply to hospital products. Also, extras cover policies can no longer include any metal, gemstone or semi-precious stone in their product name (e.g. ‘Diamond’ or ‘Platinum’ extras policies are no longer allowed).
However, a full range of extras policies are still available, including top-level extras products. Also, some combined policies (hospital and extras) may be named Gold hospital and extras.
Is Gold tier health insurance worth it?
Gold health insurance may be worth it if you’ll benefit from a wider range of coverage (e.g. pregnancy and birth, joint replacements and more).
However, if a Gold plan is outside your budget and you don’t need to include certain clinical categories on your policy (e.g. if you’re an older Australian and no longer require cover for pregnancy), 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 still be able to get the coverage that’s important to you, and it may even be more affordable than Gold.
For example, if you want cover for a knee replacement in the future, you may be able to find a Silver Plus policy which includes ‘joint replacements’.
Meet our health insurance expert, Steven Spicer
As the Executive General Manager of Health, Life and Energy, Steven Spicer is a strong believer in the benefits of private cover and knows just how valuable the peace of mind that comes with cover can be. He is passionate about demystifying the health insurance industry and advocates for the benefits of comparison when it comes to saving money on your premiums.
Want to know more about health insurance?
^Restricted cover: Your insurer will pay a limited benefit for any private hospital costs in that category. You might have to pay significant out-of-pocket costs.
*Unrestricted cover: Your insurer is likely to have an agreement with a hospital. You might not have to pay any out-of-pocket costs other than the agreed excess or co-payments.