Four new tiers of hospital cover will begin 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.
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 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.
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 unplanned complications then arise which are outside the scope of your policy, then your insurer is required to cover the treatment of the complication.
However, the insurer is only required to do so within the same episode of care as the original treatment. The unplanned treatment must be considered medically urgent and necessary in the view of the medical practitioner providing the treatment.
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.
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.
|Hospital psychiatric services||R||R||R||Y|
|Brain and nervous system||RCP||Y||Y||Y|
|Eye (not cataracts)||RCP||Y||Y||Y|
|Ear, nose and throat||RCP||Y||Y||Y|
|Tonsils, adenoids and grommets||RCP||Y||Y||Y|
|Bone, joint and muscle||RCP||Y||Y||Y|
|Kidney and bladder||RCP||Y||Y||Y|
|Male reproductive system||RCP||Y||Y||Y|
|Hernia and appendix||RCP||Y||Y||Y|
|Miscarriage and termination of pregnancy||RCP||Y||Y||Y|
|Chemotherapy, radiotherapy and immunotherapy for cancer||RCP||Y||Y||Y|
|Breast surgery (medically necessary)||RCP||Y||Y||Y|
|Diabetes management (excluding insulin pumps)||RCP||Y||Y||Y|
|Heart and vascular system||RCP||Y||Y|
|Lung and chest||RCP||Y||Y|
|Back, neck and spine||RCP||Y||Y|
|Plastic and reconstructive surgery (medically necessary)||RCP||Y||Y|
|Podiatric surgery (provided by a registered podiatric surgeon)||RCP||Y||Y|
|Implantation of hearing devices||RCP||Y||Y|
|Dialysis for chronic kidney failure||RCP||Y|
|Pregnancy and birth||RCP||Y|
|Assisted reproductive services||RCP||Y|
|Weight loss surgery||RCP||Y|
|Pain management with device||RCP||Y|
|Y||Indicates the clinical category is a minimum requirement of the product tier. The clinical category must be covered on an unrestricted basis, covering you as a private patient in a public or private hospital.|
|R||Indicates the clinical category is a minimum requirement of the product tier. The clinical category may be offered on a restricted cover basis in Basic, Bronze and Silver product tiers only. 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.|
|RCP||Restricted cover permitted: indicates the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories on a restricted or unrestricted 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.|
|A blank cell indicates that the clinical category is not a minimum requirement of the product tier. Insurers may choose to offer these as additional clinical categories; however it must be on an unrestricted basis, covering you as a private patient in a public or private hospital, with choice of doctor.|