Four new tiers of hospital cover began rolling out from early 2019 and became mandatory from 1 April 2020. All hospital insurance policies are classified as Gold, Silver, Bronze or Basic.
As part of various private health insurance changes, four new tiers of hospital cover began rolling out from 1 April 2019 and became mandatory from 1 April 2020. All hospital insurance policies are classified as Gold, Silver, Bronze or Basic.
In order to be classified in a tier, the policy has to meet the minimum requirements of that tier as set out in the table below. All treatments in the table below refer to treatment received as part of a hospital admission.
Each of the clinical categories listed below are groups of what hospital treatments are, and are not, covered under each policy.
If a policy meets the minimum requirements of a tier, but also includes additional coverage, then it can be called a ‘Plus’ policy – for example, Bronze Plus or Silver Plus.
Each standard category—for example, ‘bone, joint and muscle’ category or ‘heart and vascular system’ category—sets out the hospital treatments that must be covered by your private health insurer. If a policy covers a certain category, then it must cover everything listed in it—not only some things.
If you are admitted to hospital for a planned treatment which is included in your policy and complications arise which are outside the scope of your policy, then your insurer is required to cover the treatment of the complication. For example, if a person has surgery for a digestive illness and they develop acute arrhythmia during the episode of hospital treatment, treatment by a cardiologist and cardioversion would be covered even if the person’s policy did not otherwise cover the Heart and vascular system clinical category.
If you are admitted to hospital for a planned treatment included in your policy, and your doctor finds during the admission you have another condition requiring urgent treatment, this ‘associated unplanned treatment’ must be covered by the insurer regardless of whether treatment is within the scope of your policy. Insurers are required to cover an associated unplanned treatment which is not otherwise included in a policy where the treatment is provided within the same episode of care as the original treatment. The associated unplanned treatment must be considered medically urgent and necessary in the view of the medical practitioner providing the treatment.
Insurers are required to cover elective procedures that are covered by your policy, and all associated services or complications arising from that procedure.
However, your insurer does not have to cover any planned elective procedures not covered by your policy, even if it is provided in the same admission.
For example, a patient with a Bronze policy has elective surgery for the removal of their tonsils and also elects to have dental surgery in the same admission; their policy only covers the tonsillectomy and not the dental surgery. Their insurer is only required to cover the tonsillectomy and associated services such as post-operative care for the tonsillectomy.
The following table provides a summary of which hospital tiers cover each clinical category. For detailed information, such as the Medicare Benefit Schedule (MBS) item numbers included in each category, please see Clinical categories.
|Rehabilitation||Y (R)||Y (R)||Y (R)||Y|
|Hospital psychiatric services||Y (R)||Y (R)||Y (R)||Y|
|Palliative care||Y (R)||Y (R)||Y (R)||Y|
|Brain and nervous system||O (R)||Y||Y||Y|
|Eye (not cataracts)||O (R)||Y||Y||Y|
|Ear, nose and throat||O (R)||Y||Y||Y|
|Tonsils, adenoids and grommets||O (R)||Y||Y||Y|
|Bone, joint and muscle||O (R)||Y||Y||Y|
|Joint reconstructions||O (R)||Y||Y||Y|
|Kidney and bladder||O (R)||Y||Y||Y|
|Male reproductive system||O (R)||Y||Y||Y|
|Digestive system||O (R)||Y||Y||Y|
|Hernia and appendix||O (R)||Y||Y||Y|
|Gastrointestinal endoscopy||O (R)||Y||Y||Y|
|Miscarriage and termination of pregnancy||O (R)||Y||Y||Y|
|Chemotherapy, radiotherapy and immunotherapy for cancer||O (R)||Y||Y||Y|
|Pain management||O (R)||Y||Y||Y|
|Breast surgery (medically necessary)||O (R)||Y||Y||Y|
|Diabetes management (excluding insulin pumps)||O (R)||Y||Y||Y|
|Heart and vascular system||O (R)||O||Y||Y|
|Lung and chest||O (R)||O||Y||Y|
|Back, neck and spine||O (R)||O||Y||Y|
|Plastic and reconstructive surgery (medically necessary)||O (R)||O||Y||Y|
|Dental surgery||O (R)||O||Y||Y|
|Podiatric surgery (provided by a registered podiatric surgeon)||O (R)||O||Y||Y|
|Implantation of hearing devices||O (R)||O||Y||Y|
|Joint replacements||O (R)||O||O||Y|
|Dialysis for chronic kidney failure||O (R)||O||O||Y|
|Pregnancy and birth||O (R)||O||O||Y|
|Assisted reproductive services||O (R)||O||O||Y|
|Weight loss surgery||O (R)||O||O||Y|
|Insulin pumps||O (R)||O||O||Y|
|Pain management with device||O (R)||O||O||Y|
|Sleep studies||O (R)||O||O||Y|
|Y||Indicates the clinical category is a minimum requirement of the product tier.|
|(R)||Restricted cover permitted: insurers are allowed to offer cover for this clinical category on a restricted basis. A restricted benefit means you are partially covered for hospital costs as a private patient in a public hospital. You may incur significant expenses in a private room or private hospital so you should check with your insurer and hospital for details.|
|O||Optional for the insurer to include: insurers may choose to offer these as additional clinical categories. |