What are Health Insurance tiers?

Back in 2019, the Australian Government introduced a series of reforms to make Private Health Insurance a lot clearer. Insurers are now required to classify their hospital products according to a minimum standard, set by the government.¹ 

These days, all hospital policies must have one of the following categories included the policy name: basic, bronze, silver and gold. For example, a gold policy might go by the name ‘Premium Gold Hospital Cover’. 

Depending on which policy you choose, you’ll also receive one of the following cover types, or a combination of both for different treatments: 

• Unrestricted cover: Helps cover the costs when you’re treated in a private hospital or in a public hospital as a private patient. This is provided the hospital has an agreement with your health fund. It also allows you to choose your own treating doctor.
• Restricted cover: Only covers (partial) treatment as a private patient in a public hospital.² This still allows you to choose your treating doctor.

Each tier of insurance needs to give you a certain level of restricted and unrestricted cover as a minimum requirement. Basic cover is the exception here — as it only has to provide restricted cover for certain treatments. 

What does a Basic Health Insurance policy cover?

A Basic hospital policy allows you to access the following treatments as a minimum requirement, however, restrictions may apply:

• Rehabilitation 
• Hospital psychiatric services 
• Palliative care

If you take out Basic cover, your insurer may offer additional clinical categories on a restricted or unrestricted basis. These policies are known as Basic plus [+] policies. 

What does a Bronze Health Insurance policy cover?

A Bronze hospital policy will typically offer the same restricted cover for rehabilitation, hospital psychiatric services, and palliative care, but it will also provide unrestricted cover for the following treatments: 

• Brain and nervous system 
• Eye (not cataracts) 
• Ear, nose, and throat 
• Tonsils, adenoids, and grommets 
• Bone, joint, and muscle 
• Joint reconstructions 
• Kidney and bladder 
• Male reproductive system 
• Digestive system 
• Hernia and appendix 
• Gastrointestinal endoscopy 
• Gynaecology 
• Miscarriage and termination of pregnancy 
• Chemotherapy, radiotherapy, and immunotherapy for cancer 
• Pain management 
• Skin 
• Breast surgery (medically necessary) 
• Diabetes management (excluding insulin pumps)

If you take out a Bronze hospital policy, your insurer may include benefits towards other clinical categories, which are found in higher levels of cover. These types of policies are referred to as Bronze plus [+] policies. 

What does a Silver Health Insurance policy cover?

A Silver hospital policy covers you for the same hospital treatments found in the basic and bronze policies, but it will also cover you for the following treatments on an unrestricted basis: 

• Heart and vascular system 
• Lung and chest 
• Blood 
• Back, neck, and spine 
• Plastic and reconstructive surgery (medically necessary) 
• Dental surgery 
• Podiatric surgery (provided by an accredited podiatric surgeon) 
• Implantation of hearing devices

If you opt for Silver hospital cover, your insurer may offer additional cover for some of the clinical categories found in Gold cover. These policies are referred to as Silver plus [+] policies. 

What does a Gold Health Insurance policy cover?

A Gold hospital policy offers unrestricted cover for all of the treatments and services covered in the Basic, Bronze, and Silver tiers. It also includes you unrestricted cover for the following clinical treatments: 

• Cataracts 
• Joint replacement 
• Dialysis for chronic kidney failure 
• Pregnancy and birth 
• Assisted reproductive services 
• Weight loss surgery 
• Insulin pumps 
• Pain management with device 
• Sleep studies

A Gold hospital policy is the ultimate level of cover. It offers unrestricted cover for the full range benefits included in each of the clinical categories. 

Is there an easy way to compare what each tier covers?

Absolutely! We’ve put together a handy table that you can skim and locate all the treatments that interest you. This will show you the minimum requirements³ that each product tier will cover:

R Restricted cover | X No requirement to cover | ✓ Unrestricted cover

Do these tiers affect complications and unplanned treatment?

In addition to the minimum requirements above, all hospital policies have to make exceptions for certain complications and unplanned treatments.⁴ For example:  

• Insurers must cover any complications that arise from a planned treatment included in your policy.⁵ It doesn’t matter if the treatment for this complication isn’t covered by your policy; all that matters is if your policy covers the original reason you were admitted to hospital.
• Insurers must also cover unplanned treatment in certain conditions.⁶ If you’re admitted to hospital for a (planned) treatment your policy covers, and while you’re there, the doctor discovers you have another condition that needs urgent treatment, then your insurer will also need to cover this unplanned treatment.

Remember, no insurer can refuse to cover you for a treatment in the above circumstances. This means one less thing to worry about when selecting Private Health Insurance. 

How much does each tier of hospital cover cost?

A lot of different factors can affect how much hospital cover costs. Among other things, this can vary depending on your insurer, your excess⁷ and whether a Lifetime Health Cover (LHC) loading applies.⁸ 

However, all things being equal, a policy that provides more cover will usually cost more.⁹

This means that gold hospital cover from an insurer will typically cost more than basic hospital cover from the same insurer. So, as with most insurance, getting the right price and a suitable level of cover can be a bit of a balancing act. 

Do product tiers apply to extras cover?

No, insurers aren’t required to use any general categories for extras cover. Extras cover refers to cover for general treatments—the kind where you don’t usually have to go to hospital — like dental checkups, physiotherapy or speech therapy.¹⁰ 

There can be a lot of differences between extras policies in terms of what is and isn’t covered. And insurers can also differ on how much they’ll pay in benefits for different treatments. 

On one hand, this means you’ll have to take each extras policy on a case-by-case, which can involve a bit more research. On the other hand, this gives you a bit more flexibility with your coverage; some insurers even let you pick and choose the benefits you want, ‘building’ the policy to your liking.¹¹ That way, you might be able to avoid paying more for extras treatments you don’t need. 

Find a Health Insurance policy with iSelect

We get it. After reading everything here, comparing Private Health Insurance policies might be the last thing you want to do. But here's our little secret: it doesn't have to be some drawn-out snoozefest. 

iSelect has you covered with a quick and easy way to compare Hospital Cover. You can compare Health Insurance online or call us on 1800 784 772 with a range of providers*—and all in a matter of minutes! Not too bad for your friendly neighbourhood comparison service, eh? 

^{Sources:
1 PrivateHealth.org.au - Private Health Insurance Changes 
2 PrivateHealth.gov.au - Product Tiers 
3 Australian Government | Department of Health and Aged Care -  Private health insurance reforms: gold, silver, bronze, basic product tiers fact sheet (page 2) 
4 Privatehealth.gov.au - Product tiers 
5 As above.  
6 As above. 
7 Australian Competition & Consumer Commission - Private health insurance
8 Australian Tax Office - Lifetime health cover
9 PrivateHealth.gov.au - Managing your policy 
10 Australian Government | Department of Aged and Health Care - Extras and ambulance cover 
11 Bupa - Flexible Extras Cover}