Hospital cover: the new tiers and categories explained

The government introduced new tiers, clinical categories and definitions to make hospital cover easier to understand. Learn what they are and why they matter.

Health Agenda
April 2019

With the government’s key private health insurance reforms taking effect on 1 April 2019, there’s a lot of change to get your head around. And given the amount of media coverage the reforms are getting you may be confused about what it all means.

Here, we’re going to focus on the reforms designed to help you understand exactly what hospital insurance does and doesn’t cover.

This matters because it’s the key to figuring out whether a policy is right for you, and avoiding bill shock. It’ll also help you compare what different health funds are offering.

All the changes we’re talking about came into effect on 1 April 2019.

Gold, Silver, Basic and Bronze tiers

All Australian health funds have to fit their hospital cover into one of 4 tiers: Gold, Silver, Bronze and Basic. Gold gives you the highest coverage, and Basic is just that.

The tiers are more than helpful names, they tell you what the policy will definitely include at a mimimum. That’s because cover that sits in each tier has to include certain groups of treatments or services (called clinical categories).

If there’s any other treatments or services added to a policy in-between tiers you’ll find the word ‘plus’ in the name (e.g. HCF Hospital Silver Plus).

Clinical categories and definitions

A clinical category describes a group of treatments or services. Examples include Back, neck and spine or Digestive system.

As with the tiers, each category has to include certain treatments and services. That’s where clinical definitions come into play.

For example:

• Category: Back neck and spine
• Clinical definitions: Treatment for sciatica, prolapsed or herniated disc, spine curvature disorders like scoliosis, kyphosis and lordosis, and more.

All health funds have to use the same wording for these categories and definitions, so you really can compare like for like.

Any questions?

If you have questions about the reforms, get in touch. You can call us on 13 13 34 or visit a branch.

If you’re an HCF member who’s planning to have hospital treatment and are unsure whether you’re covered for it, please get in touch before you’re treated. Ask your doctor for all the relevant Medicare ‘item numbers’ and we’ll talk you through the costs and advise however we can.