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NIBIf you’re looking for a health insurance policy, the new health insurance categories should simplify your search.
The four private health insurance tiers consist of Gold, Silver, Bronze and Basic. Each health insurance tier has a minimum set of hospital treatments (defined by clinical categories) that must be included. However, health funds can include other types of treatments (that are not mandatory) to expand their offering.
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Why did Australia get a tiered health insurance system?
The Australian Government introduced the 4 private health insurance categories (Gold, Silver, Bronze and Basic) from 1 April 2019 to provide more certainty. The changes help you choose the type of cover that suits your unique requirements. Each tier must adhere to a minimum clinical category requirement, enabling you to shop around and compare different hospital policies more efficiently.
All private health insurance providers must apply the four-tiered system by April 2020.
For an overview of all the recent private health insurance updates, read our guide on government changes to private health insurance.
How does the new health insurance tiers work?
Each product tier has a different minimum clinical category that must be applied. A clinical category refers to a group of hospital treatments, for example, the Heart and Vascular system category.
If a policy provides cover for a specific clinical category, then it must provide coverage for all hospital treatment that falls within the scope of that clinical category.
However, if an insurer chooses to add a clinical category that’s not mandatory for that specific product tier, they can decide to offer it on a Restricted (R) basis. Treatments that are Restricted provides coverage as a private patient in a public hospital, up to a specific benefit limit.
What are the different health insurance tiers?
The four levels of private health insurance start at the most basic of hospital cover options and extend to the most comprehensive: Basic, Bronze, Silver and Gold. Each policy includes a minimum list of clinical categories. Generally, the more inclusive the product tier, the higher your premium.
What is Gold cover health insurance?
A Gold health insurance policy is the top-level hospital plan, covering all 38 clinical categories. This comprehensive option might be worth considering if you’re planning to start or expand your family or if you require a higher level of health care. The Gold plan is also the only option offering unrestrictive coverage for rehabilitation, hospital psychiatric services and palliative care.
Hospital treatments only available with a Gold hospital policy include:
- Pregnancy and birth-related services
- Assisted reproductive services
- Joint replacements
- Cataract
- Dialysis of chronic kidney failure
- Insulin pumps
- Pain management devices
- Weight loss surgery
- Sleep studies
What is Silver health insurance?
The Silver hospital policy was previously referred to by many insurers as the Mid or Medium level plan. It provides coverage for 29 clinical categories, including heart and vascular system, dental surgery, medically necessary plastic surgery and the implantation of hearing devices. However, it excludes all pregnancy and birth-related treatments and services.
The Bronze product tier
Bronze health insurance is a lower cost option that provides a benefit for 21 clinical categories, for example, joint reconstruction, investigation and repair of hernia and appendix, and gastrointestinal endoscopy. The Bronze plan might be worth considering if you’re relatively healthy and not planning to have children anytime soon.
The Basic health insurance plan
If you’re young and healthy and only want some level of coverage in case of an accident, the Basic hospital plan might be for you. This plan also includes restrictive coverage for rehabilitation, hospital psychiatric services and palliative care. Generally, Basic health insurance will help you avoid the Medicare Levy Surcharge (MLS) and Lifetime Health Cover (LHC) loading.
Compare the four private health insurance tiers
| Clinical Category | Basic | Bronze | Silver | Gold |
| Rehabilitation | (R) | (R) | (R) | |
| Hospital psychiatric services | (R) | (R) | (R) | |
| Palliative care | (R) | (R) | (R) | |
| Brain and nervous system | O (R) | |||
| Eye (not cataracts) | O (R) | |||
| Ear, nose and throat | O (R) | |||
| Tonsils, adenoids and grommets | O (R) | |||
| Bones, joints, and muscles | O (R) | |||
| Joint reconstructions | O (R) | |||
| Kidney and bladder | O (R) | |||
| Male reproductive system | O (R) | |||
| Digestive system | O (R) | |||
| Hernia and appendix | O (R) | |||
| Gastrointestinal endoscopy | O (R) | |||
| Gynaecology | O (R) | |||
| Miscarriage and termination of pregnancy | O (R) | |||
| Chemotherapy, radiotherapy and immunotherapy for cancer | O (R) | |||
| Pain management | O (R) | |||
| Skin | O (R) | |||
| Breast surgery (medically necessary) | O (R) | |||
| Diabetes management (excluding insulin pumps) | O (R) | |||
| Lung and chest | O (R) | O | ||
| Blood | O (R) | O | ||
| Back, neck and spine | O (R) | O | ||
| Plastic and reconstructive surgery (medically necessary) | O (R) | O | ||
| Dental surgery | O (R) | O | ||
| Podiatric surgery (provided by an accredited podiatric surgeon) | O (R) | O | ||
| Implantation of hearing devices | O (R) | O | ||
| Cataracts | O (R) | O | O | |
| Joint replacements | O (R) | O | O | |
| Dialysis for chronic kidney failure | O (R) | O | O | |
| Pregnancy and birth | O (R) | O | O | |
| Assisted reproductive services | O (R) | O | O | |
| Weight loss surgery | O (R) | O | O | |
| Insulin pumps | O (R) | O | O | |
| Pain management with device | O (R) | O | O | |
| Sleep studies | O (R) | O | O |
Source: privatehealth.gov.au
| The clinical category is a minimum requirement for this health insurance tier. | |
| (R) | Restrictive cover. The benefit paid toward the hospital cost of treatment is restricted to the amount required under Private Health Insurance Rules. |
| O | Optional. The health fund can include this treatment as restrictive or unrestrictive. |
Frequently asked questions
Will these new health insurance categories affect my existing health cover?
Yes, your policy’s name will change, and you might lose and/or gain cover for specific treatments and services. All health insurance policies will be moved to the new tiering system before 1 April 2020. Your existing plan will convert to the new system if it hasn’t done so already. Which means your cover might have already changed.
Your health fund would have communicated these changes to you, typically via email. If you have not received information regarding the Gold, Silver, Bronze health insurance categories, please call your insurer and make sure you know exactly what you’re covered for.Which tier does my current policy fall in to?
It depends on your health insurance company. If your policy has been updated to the new system, you can find out the details by visiting the privatehealth.goc.au website and reading the detailed Private Health Insurance Information Statement (PHIS). However, it’s best to contact your insurer directly and have a consultant explain which tier your current cover is changing to.Will my premium change with the new private health insurance tiers?
The Minister must first approve any changes to health insurance premiums, and then it must be provided to the Private Health Insurance Ombudsman within 14 days of the date of the Minister’s approval. That is why health insurance prices usually only change on 1 April each year. Thus, the private health insurance reforms 2019/2020 generally won’t in a premium change without first going through the above process.What does it mean when there’s a plus (+) in the policy?
When a health insurance plan includes coverage for a clinical category that is not mandatory in that product tier, then the health fund may use the word ‘plus’ or the + symbol in the name of the policy. The ‘plus’ indicates the insurer includes additional services on top of the minimum requirements.Where does ambulance cover fit into these new product tiers?
Ambulance services are not recognised as a clinical category. However, health insurance companies can continue to offer ambulance cover with their hospital policies, enabling them to include the ‘plus’ (+) symbol.Does waiting periods differ between categories?
Generally, no. Waiting periods are determined by the health fund, not by your level of coverage. The new tiering system does not affect your waiting period.Which new health insurance category is the best?
It depends on your requirements and what you can afford. For example, if you’re planning to get pregnant, then a Gold level health insurance plan might be the best. It’s always a good idea to speak with a specialist to help you compare health plans to find one suited to your stage of life and budget.
