Hospital cover and product tiers

Hospital cover helps with the costs of treatment as a private patient in hospital. If you have private hospital cover, you can choose to be treated as a private patient in a public hospital, private hospital or day hospital facility.

Hospital services

Depending on the hospital cover you take out, private health insurance covers some or all of:

  • hospital accommodation costs (including meals)
  • theatre costs

In-hospital doctor and specialist services

Depending on the hospital cover you take out, private health insurance covers some or all of the medical services that Medicare covers.

See the list of Medicare Benefits Schedule (MBS) services, which includes an MBS fee for each service.

Medicare covers 75% of the MBS fee and private health insurance covers at least 25%.

If your doctor or specialist charges more than the MBS fee for their service, you may have to pay the extra out of your own pocket. Find out how much you can expect to pay by using the Medical Costs Finder.

Second-tier default benefits for private hospital patients

If you are treated in a hospital that does not have an agreement with your insurer but which we have assessed as second-tier default benefits eligible, you will still receive a benefit from your insurer.

Learn more about second-tier default benefits.

Restrictions and exclusions

Restrictions

Restrictions are services that a plan partly covers.

For example, if your policy restricts hip replacement:

  • you’re covered as a private patient in a public hospital
  • you’re partly covered as a private patient in a private hospital — this means your health insurer will only pay a small part of your hospital accommodation fees and you’ll have to pay for all other costs

Exclusions

Exclusions are services that a policy doesn’t cover. This means your health insurer will not pay for any of the costs of the service.

For example, some policies don’t cover services like:

  • heart surgery
  • knee and hip replacements
  • cataract surgery
  • pregnancy and birth-related services

See the Commonwealth Ombudsman’s guidance on policy exclusions and restrictions.

Private patients’ hospital charter

Learn more about what you should know about treatment costs and your rights and responsibilities in the Private patients’ hospital charter.

Private health insurance product tiers – Gold, Silver, Bronze and Basic cover

From April 2020, all hospital insurance products must be classified as one of four tiers:

  • Gold
  • Silver
  • Bronze
  • Basic

Your insurer will assign existing policies to a tier based on the level of cover it provides. They will let you know what tier your policy is.

How product tiers work

We’ve grouped standardised hospital treatments into clinical categories.

A policy is assigned a tier based on the minimum level of cover it offers against these clinical categories.

If your insurer offers a policy that provides cover above the minimum requirements of a tier they can promote the policy as Basic Plus (+), Bronze Plus (+) or Silver Plus (+).

View our product tiers fact sheet for a table showing the cover each tier must provide for each clinical category.

Find out more about product tiers on the Private Health website.

We will soon start a review of the product tiers to make sure they are working as planned.

Last updated: 
21 October 2020

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