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.

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

How product tiers work

We’ve published a list of standardised hospital treatments, or clinical categories.

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

Depending on your policy tier, your insurer might:

  • provide no cover for some categories
  • provide limited, or restricted, coverage against some categories, or
  • provide unrestricted cover against some or all categories

Restricted cover means your insurer will pay part of any private hospital costs against that category. You might have to pay large out of pocket costs.

Unrestricted cover means your insurer is likely to have an agreement with a hospital. You might not have to pay any out of pocket costs other than any agreed excess or co-payments.

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 (+).

Existing policies

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.

Compare policy tiers by cover

This table shows what level of cover each tier must provide against each clinical category.

Clinical categories for hospital cover

This list shows which hospital treatments must be covered under each clinical category.

Assisted reproductive services

Hospital treatment for fertility treatments or procedures. For example:

  • retrieval of eggs or sperm
  • In Vitro Fertilisation (IVF)
  • Gamete Intra‑fallopian Transfer (GIFT)

Not in this category — included in other categories:

Back, neck and spine

Hospital treatment for the investigation and treatment of the back, neck and spinal column, including spinal fusion. For example:

  • sciatica
  • prolapsed or herniated disc
  • spinal disc replacement
  • spine curvature disorders such as scoliosis, kyphosis and lordosis

Not in this category — included in other categories:

Blood

Hospital treatment for the investigation and treatment of blood and blood related conditions. For example:

  • blood clotting disorders
  • bone marrow transplants

Not in this category — included in other categories:

Bone, joint and muscle

Hospital treatment for the investigation and treatment of diseases, disorders and injuries of the musculoskeletal system. For example:

  • carpal tunnel
  • fractures
  • hand surgery
  • joint fusion
  • bone spurs
  • osteomyelitis
  • bone cancer

Not in this category — included in other categories:

Brain and nervous system

Hospital treatment for 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
  • Parkinson’s disease

Not in this category — included in other categories:

Breast surgery (medically necessary)

Hospital treatment for 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
  • gynecomastia

This clinical category does not require benefits to be paid for cosmetic breast surgery that is not medically necessary.

Not in this category — included in other categories:

Cataracts

Hospital treatment for surgery to remove a cataract and replace with an artificial lens.

Chemotherapy, radiotherapy and immunotherapy for cancer

Hospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours.

Surgical treatment of cancer is listed separately under each body system.

Dental surgery

Hospital treatment for surgery to the teeth and gums, such as:

  • surgery to remove wisdom teeth
  • dental implant surgery

Diabetes management (excluding insulin pumps)

Hospital treatment for the investigation and management of diabetes, such as:

  • 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. For example:

  • treatment for diabetes related eye conditions — in eye
  • treatment for ulcers — in digestive system
  • provision and replacement of insulin pumps — in insulin pumps

Dialysis for chronic kidney failure

Hospital treatment for dialysis treatment for chronic kidney failure, such as:

  • peritoneal dialysis
  • haemodialysis

Digestive system

Hospital treatment for 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
  • haemorrhoids

Not in this category — included in other categories:

Ear, nose and throat

Hospital treatment for the investigation and treatment of the ear, nose, throat, middle ear, thyroid, parathyroid, larynx, lymph nodes and related areas of the head and neck. For example:

  • damaged ear drum
  • sinus surgery
  • removal of foreign bodies
  • stapedectomy
  • throat cancer

Not in this category — included in other categories:

Eye (not cataracts)

Hospital treatment for the investigation and treatment of the eye and the contents of the eye socket. For example:

  • retinal detachment
  • tear duct conditions
  • eye infections
  • medically managed trauma to the eye

Not in this category — included in other categories:

Gastrointestinal endoscopy

Hospital treatment for the diagnosis, investigation and treatment of the internal parts of the gastrointestinal system using an endoscope. For example:

  • colonoscopy
  • gastroscopy
  • endoscopic retrograde cholangiopancreatography (ERCP)

Not included in this category — included in other categories:

Gynaecology

Hospital treatment for the investigation and treatment of the female reproductive system. For example:

  • endometriosis
  • polycystic ovaries
  • female sterilisation
  • cervical cancer

Not in this category — included in other categories:

Heart and vascular system

Hospital treatment for 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
  • removal of plaque from arterial walls

Not in this category — included in other categories:

Hernia and appendix

Hospital treatment for the investigation and treatment of a hernia or appendicitis.

Not in this category — included in other categories:

Hospital psychiatric services

Hospital treatment for the treatment and care of patients with psychiatric, mental, addiction or behavioural disorders. For example:

  • psychoses such as schizophrenia
  • mood disorders such as depression
  • eating disorders
  • addiction therapy

Implantation of hearing devices

Hospital treatment to correct hearing loss, including implantation of a prosthetic hearing device.

Not in this category — included in other categories:

Insulin pumps

Hospital treatment for the provision and replacement of insulin pumps for treatment of diabetes.

Joint reconstructions

Hospital treatment for surgery for joint reconstructions. For example:

  • torn tendons
  • rotator cuff tears
  • damaged ligaments

Not in this category — included in other categories:

Joint replacements

Hospital treatment for 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

Not in this category — included in other categories:

Kidney and bladder

Hospital treatment for the investigation and treatment of the kidney, adrenal gland and bladder. For example:

  • kidney stones
  • adrenal gland tumour
  • incontinence

Not in this category — included in other categories:

Lung and chest

Hospital treatment for the investigation and treatment of the lungs, lung‑related conditions, mediastinum and chest. For example:

  • lung cancer
  • respiratory disorders such as asthma or pneumonia
  • treatment of trauma to the chest

Not in this category — included in other categories:

Male reproductive system

Hospital treatment for the investigation and treatment of the male reproductive system including the prostate. For example:

  • male sterilisation
  • circumcision
  • prostate cancer

Not in this category — included in other categories:

Miscarriage and termination of pregnancy

Hospital treatment for the investigation and treatment of a miscarriage or for termination of pregnancy.

Pain management

Hospital 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

Not in this category — included in other categories:

Pain management with device

Hospital treatment for 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)

Not in this category — included in other categories:

Palliative care

Hospital treatment for care where the intent is primarily providing quality of life for a patient with a terminal illness, including treatment to alleviate and manage pain.

Plastic and reconstructive surgery (medically necessary)

Hospital 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
  • angioma

Not in this category — included in other categories:

Podiatric surgery (provided by a registered podiatric surgeon)

Hospital treatment for the investigation and treatment of conditions affecting the foot and/or ankle, provided by a registered podiatric surgeon, but limited to cover for:

Note: Insurers are not required to pay for any other benefits for hospital treatment for this clinical category but may choose to do so.

Pregnancy and birth

Hospital treatment for investigation and treatment of conditions associated with pregnancy and child birth.

Not in this category — included in other categories:

Rehabilitation

Hospital treatment for physical rehabilitation for a patient related to surgery or illness. For example:

  • inpatient and admitted day patient rehabilitation
  • stroke recovery
  • cardiac rehabilitation

Skin

Hospital treatment for the investigation and treatment of skin, skin‑related conditions and nails. The removal of foreign bodies is also included. Plastic surgery that is medically necessary and relating to the treatment of a skin‑related condition is also included. For example:

  • melanoma
  • minor wound repair
  • abscesses

Not in this category — included in other categories:

Sleep studies

Hospital treatment for the investigation of sleep patterns and anomalies. For example:

  • sleep apnoea
  • snoring

Tonsils, adenoids and grommets

Hospital treatment of the tonsils, adenoids and insertion or removal of grommets.

Weight loss surgery

Hospital treatment for 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
Last updated: 
12 February 2020

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