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Each tier of hospital cover has a certain number of clinical categories and associated hospital treatments.

The following are the minimum requirements for each hospital cover tier.

• Basic: 3 clinical categories (all restricted services with limited benefits)
• Bronze: 18 unrestricted categories plus 3 restricted categories
• Silver: 26 unrestricted categories plus 3 restricted categories
• Gold: 38 clinical categories (all unrestricted)

To be classified as Silver tier, a hospital policy in Australia must include the following:

The main difference between a Silver-tier policy and a Silver Plus policy is that a Silver Plus policy can include additional clinical categories that are not a minimum requirement. What these additional clinical categories are will vary depending on your health fund and policy.

Due to the additional clinical categories included, a Silver Plus policy will likely cost more than a Silver policy. Factors such as your choice of health fund, policy and whether you have dependants will also affect the cost.

Your premium could also be affected by the following:

• Australian government rebate: Depending on your age and income, you could be eligible for the Australian Government rebate.
• Age-based discount: If you’re under 30, you could potentially benefit from the age-based discount, allowing you to save on your premiums.
• Lifetime Health Cover loading: If you don’t take out private hospital cover before turning 31, you’ll be subject to LHC loading.
• Medicare Levy Surcharge: Having hospital cover can help
• Policy excess: Choosing a higher excess can reduce your premium.
• Location: Premiums can vary by state due to hospital agreements.

When you’re treated as a private patient, there’s a scheduled fee for each Medicare item number, which is outlined in the Medicare Benefits Schedule (MBS). Providing you have the relevant cover, Medicare and your private health fund will combine to cover 100% of this fee. However, your medical practitioner or specialist may charge more than the MBS fee. The difference between the MBS fee and the specialist fee is called the gap. Whether some or all of this gap will be covered by your policy or end up being an out-of-pocket expense will depend on your policy.

If your policy offers a gap cover scheme for particular medical services and your doctor, an anaesthetist and any assistance doctors participate, you can minimise your out-of-pocket costs. Each policy will be different, so be sure to read your policy documentation to understand the terms and conditions of your health insurance.

If you receive hospital treatment in a public hospital as a public patient, Medicare will cover your costs.

Elective surgeries usually need to be planned and booked in advance. A potential downside of public hospitals is that there are often long waiting times due to high demand. Being a private patient allows you to avoid these wait times and increase your chances of getting treatment sooner.