Product tiers

Four new tiers of hospital cover began rolling out from early 2019 and will become mandatory from 1 April 2020. All hospital insurance policies will be 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 - it must include all the required Clinical Categories for its tier. Each Clinical Category is a group of hospital treatments - for example, ‘bone, joint and muscle’ or ‘heart and vascular system’.
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As part of various private health insurance changes, four new tiers of hospital cover began rolling out from 1 April 2019 and will become mandatory from 1 April 2020. All hospital insurance policies will be classified as Gold, Silver, Bronze or Basic. 

Please note that the new product tiers and clinical categories are optional until 1 April 2020. Until 1 April 2020, some of the policies you may view on this website do not yet comply with the Gold, Silver, Bronze or Basic tiers or use the same definitions as the clinical categories. Check with your insurer for details.

Gold, Silver, Bronze and Basic hospital tiers

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.

Clinical categories

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.

Receiving treatment for complications and unplanned hospital treatment

Complications

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.

Unplanned treatment

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.

Two or more procedures where one is excluded from your policy

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.

Hospital treatment product tiers

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.

Clinical CategoryBasicBronzeSilverGold
RehabilitationY (R)Y (R)Y (R)Y
Hospital psychiatric servicesY (R)Y (R)Y (R)Y
Palliative careY (R)Y (R)Y (R)Y
Brain and nervous systemO (R)YYY
Eye (not cataracts)O (R)YYY
Ear, nose and throatO (R)YYY
Tonsils, adenoids and grommetsO (R)YYY
Bone, joint and muscleO (R)YYY
Joint reconstructionsO (R)YYY
Kidney and bladderO (R)YYY
Male reproductive systemO (R)YYY
Digestive systemO (R)YYY
Hernia and appendixO (R)YYY
Gastrointestinal endoscopy O (R)YYY
GynaecologyO (R)YYY
Miscarriage and termination of pregnancyO (R)YYY
Chemotherapy, radiotherapy and immunotherapy for cancerO (R)YYY
Pain managementO (R)YYY
SkinO (R)YYY
Breast surgery (medically necessary)O (R)YYY
Diabetes management (excluding insulin pumps)O (R)YYY
Heart and vascular systemO (R)OYY
Lung and chestO (R)O YY
BloodO (R)OYY
Back, neck and spineO (R)OYY
Plastic and reconstructive surgery (medically necessary)O (R)OYY
Dental surgery O (R)OYY
Podiatric surgery (provided by a registered podiatric surgeon)O (R)OYY
Implantation of hearing devicesO (R)O YY
CataractsO (R)O O Y
Joint replacementsO (R)O O Y
Dialysis for chronic kidney failureO (R)O O Y
Pregnancy and birthO (R)O O Y
Assisted reproductive services O (R)O O Y
Weight loss surgeryO (R)O O Y
Insulin pumpsO (R)O O Y
Pain management with deviceO (R)O O Y
Sleep studiesO (R)O O Y
YIndicates 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.