Product tiers and clinical categories

Gold, Silver, Bronze and Basic hospital tiers

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. 

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 unplanned hospital treatment

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.

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 each clinical category. For detailed information, such as the Medicare Benefit Schedule (MBS) item numbers included in each category, please see the Department of Health - Private Health Insurance Reform Rules 2018.

Clinical Category

Basic

Bronze

Silver

Gold

Rehabilitation
Physical rehabilitation related to surgery or illness. For example: stroke recovery, cardiac rehabilitation.
RRR

Y

Hospital psychiatric services
Treatment and care of patients with psychiatric, mental, addiction or behavioural disorders. For example: schizophrenia, depression, eating disorders, addiction therapy, and post-natal depression.
RRRY
Palliative care 
Providing quality of life care for a patient with a terminal illness, including treatment to alleviate and manage pain.
RRRY
Brain and nervous system 
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. 

This category does not include the treatment of spinal column conditions and chemotherapy or radiotherapy for cancer.
RCPYYY
Eye (not cataracts)
The investigation and treatment of the eye and contents of the eye socket. For example: retinal detachment, tear duct conditions, eye infections and medically managed trauma to the eye.

This category does not include cataracts, eyelid procedures, and chemotherapy and radiotherapy for cancer.
RCPYYY
Ear, nose and throat
The investigation and treatment of the ear, nose, throat, middle ear, thyroid, parathyroid, larynx, lymph nodes, and related areas of the head and neck.

This category does not include tonsils, adenoids, grommets, implantation of hearing devices, orthopaedic neck conditions, sleep studies, and chemotherapy and radiotherapy for cancer.
RCPYYY
Tonsils, adenoids and grommets
Treatment of the tonsils, adenoids, and insertion or removal of grommets.
RCPYYY
Bone, joint and muscle
Treatment for the investigation and treatment of diseases, disorders and injuries of the musculoskeletal system. For example: carpal tunnel, fractures, hand surgery, joint fusions, bone spurs, and bone cancer.

This category does not include chest surgery, spinal cord conditions, spinal column conditions, joint reconstructions, joint replacements, podiatric surgery, management of back pain, and chemotherapy and radiotherapy for cancer.
RCPYYY
Joint reconstructions
Treatment for joint reconstructions. For example: torn tendons, rotator cuff tears, and damaged ligaments.

This category does not include joint replacements, bone fractures, spinal column procedures, and podiatric surgery.
RCPYYY
Kidney and bladder
The investigation and treatment of the kidney, adrenal gland and bladder. For example: kidney stones, adrenal gland tumour and incontinence.

This category does not include dialysis and chemotherapy and radiotherapy for cancer.
RCPYYY
Male reproductive system

The investigation and treatment of the male reproductive system including the prostate. For example: male sterilisation, circumcision and prostate cancer.

This category does not include chemotherapy and radiotherapy for cancer.
RCPYYY
Digestive system
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.

This category does not include endoscopy, hernia and appendicectomy procedures, bariatric (weight loss) surgery, and chemotherapy and radiotherapy for cancer
RCPYYY
Hernia and appendix
The investigation and treatment of a hernia or appendicitis.

This category does not include digestive conditions.
RCPYYY
Gastrointestinal endoscopy

The diagnosis, investigation and treatment of the internal parts of the gastrointestinal system using an endoscope (an instrument using a camera to look inside the body) For example: colonoscopy and gastroscopy.

This category does not include non-endoscopic procedures for the digestive system.
RCPYYY
Gynaecology
The investigation and treatment of the female reproductive system. For example: endometriosis, polycystic ovaries, female sterilisation and cervical cancer.

This category does not include fertility treatments, pregnancy and birth-related conditions, miscarriage or termination of pregnancy, and chemotherapy and radiotherapy for cancer.
RCPYYY
Miscarriage and termination of pregnancy
The investigation and treatment of a miscarriage or for termination of pregnancy.
RCPYYY
Chemotherapy, radiotherapy and immunotherapy for cancer
Treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours.

This category does not include surgical treatment of cancer, which is listed separately under each body system.
RCPYYY
Pain management
Treatment for pain management that does not 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.

This category does not include pain management using a device such as an infusion pump or neurostimulator.
RCPYYY
Skin
The investigation and treatment of skin, skin related conditions and nails. This category includes the removal of foreign bodies, and plastic surgery that is medically necessary and relating to the treatment of a skin related condition. For example: melanoma, minor wound repair and abscesses.

This category does not include removal of excess skin due to weight loss, and chemotherapy and radiotherapy for cancer.
RCPYYY
Breast surgery (medically necessary)
The investigation and treatment of breast disorders and associated lymph nodes, and reconstruction and/or reduction following breast surgery or a preventative mastectomy. For example: breast lesions, breast tumours, asymmetry due to breast cancer surgery, and gynecomastia.

This category does not require benefits to be paid for cosmetic breast surgery that is not medically necessary.
RCPYYY
Diabetes management (excluding insulin pumps)
The investigation and management of diabetes. For example: stabilisation of hypo- or hyper- glycaemia, contour problems due to insulin injections.

Treatment for diabetes related conditions is listed separately under each body system affected.

This category does not include treatment for ulcers or provision and replacement of insulin pumps. 
RCPYYY
Heart and vascular system
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. Also known as cardiac services.

This category does not include chemotherapy and radiotherapy for cancer.
RCP-YY
Lung and chest
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.

This category does not include chemotherapy and radiotherapy for cancer.
RCP-YY
Blood
The investigation and treatment of blood and blood related conditions. For example: blood clotting disorders and bone marrow transplants.

This category does not include treatment for cancers of the blood.
RCP-YY
Back, neck and spine
The investigation and treatment of the back, neck and spinal column, including spinal fusion. For example: sciatica, prolapsed or herniated disc, and spine curvature disorders such as scoliosis.

This category does not include joint replacements, joint fusions, spinal cord conditions, management of back pain, and chemotherapy and radiotherapy for cancer.
RCP-YY
Plastic and reconstructive surgery (medically necessary)
Treatment which is medically necessary for the investigation and treatment of any physical deformity, whether acquired as a result of illness or accident, or congenital. For example: burns requiring a graft, cleft palate, club foot and angioma.

This category does not include treatment of skin-related conditions and chemotherapy and radiotherapy for cancer.
RCP-YY
Dental surgery

Hospital treatment for surgery to the teeth and gums. For example: surgery to remove wisdom teeth, and dental implant surgery.
RCP-YY
Podiatric surgery (provided by a registered podiatric surgeon)
The investigation and treatment of conditions affecting the foot and/or ankle, provided by a registered podiatric surgeon. This is limited to cover for hospital accommodation and the cost of a prosthesis. 

Note that insurers are not required to pay for any other benefits for podiatric surgery, such as the surgeon’s fee or medical fees such as the anaesthetist, though they may choose to do so.
RCP-YY
Implantation of hearing devices
Treatment to correct hearing loss, including implantation of a prosthetic hearing device.
RCP-YY
Cataracts
Surgery to remove a cataract and replace with an artificial lens.
RCP--Y
Joint replacements
Surgery for joint replacements, including revisions, resurfacing, partial replacements and removal of prostheses. For example: replacement of shoulder, wrist, finger, hip, knee, ankle, or toe joint, spinal disc replacement.

This category does not include joint fusions, spinal fusions, joint reconstructions, and podiatric surgery performed by a registered podiatric surgeon.
RCP--Y
Dialysis for chronic kidney failure
Dialysis treatment for chronic kidney failure (renal failure). For example: peritoneal dialysis and haemodialysis.
RCP--Y
Pregnancy and birth
Investigation and treatment of conditions associated with pregnancy and child birth. Also known as obstetrics.

This category does not include treatment for the baby (this is covered under the clinical category relevant to their condition), female reproductive conditions, fertility treatments, miscarriage and termination of pregnancy.
RCP--Y
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).

This category does not include treatment of the female reproductive system, and pregnancy and birth-related services.

RCP--Y
Weight loss surgery
Surgery that is designed 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, sleeve gastrectomy.
RCP--Y
Insulin pumps
The provision and replacement of insulin pumps for treatment of diabetes.
RCP--Y
Pain management with device
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 (for example an infusion pump or neurostimulator).

This category does not include treatment of pain that does not require a device.
RCP--Y
Sleep studies
The investigation of sleep patterns and anomalies. For example: sleep apnoea and snoring.
RCP--Y
YIndicates 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.
RIndicates 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.
RCPRestricted 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.