Explained: Bronze, Silver & Gold Tier Health Insurance
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Understanding the hospital covers tiering system

Starting in April 2020, all private hospital covers had to offer their products by a standardised tiering system: Gold, Silver, Bronze, and Basic. All hospital cover products must be categorised as one of these four tiers. Health insurance providers are required to provide all the hospital treatments specified in each tier at minimum but are allowed to include more in each tier to be competitive. The tiering system was designed to make comparison easier and help consumers make more informed choices for their needs.

There are a few things you as a customer are entitled to in this new tiering system. First, all treatments and procedures listed in each hospital treatment category must be covered if the category is offered in the product. For instance, if the ‘heart and vascular system’ category is offered in the policy, all procedures related to that category must be covered. Insurers cannot cherry-pick the procedures or treatments. Second, insurers are required to cover elective procedures that are covered by the policy as well as all associated services or complications arising from that procedure. For example, if you have a procedure done for a lung condition and develop unexpected complications which require digestive care, that care must be covered as well even if the digestive system is not offered by the policy. Third, urgent treatments for unplanned accidents or illnesses must be covered by the insurer whether such treatment is offered by the policy or not.

Here are the clinical categories that must be included in each tier.

  • (R) = Required minimum
  • (L) = Allowed to cover on a restricted basis with limited benefits
  • (O) = Optional for insurance providers to offer if desired
Clinical CategoryDescriptionBasicBronzeSilverGold
RehabilitationPhysical rehabilitation for an in-house patient related to surgery or illness such as stroke recovery(R) (L)(R) (L)(R) (L)(R)
Hospital psychiatric servicesIn-hospital treatment for psychiatric, mental, addiction or behavioural disorders(R) (L)(R) (L)(R) (L)(R)
Palliative carePain management for terminally ill patients(R) (L)(R) (L)(R) (L)(R)
Brain & nervous systemAssessment and treatment of brain-related conditions, spinal cord and peripheral nervous system(O)(R)(R)(R)
Eye (not cataracts)All eye-related treatments and illnesses other than cataracts or eyelid procedures(O)(R)(R)(R)
Ear, nose and throatAssessment and treatment of the ear, nose, throat, middle ear, thyroid, parathyroid, larynx, and lymph nose(O)(R)(R)(R)
Tonsils, adenoids and grommetsTreatment of tonsils and adenoids and insertion or removal of grommets(O)(R)(R)(R)
Bone, joint and muscleTreatment of diseases, disorders and injuries of the musculoskeletal system such as hand surgery, bone spurs, etc.(O)(R)(R)(R)
Joint reconstructionsJoint reconstructive procedures to treat conditions such as damaged ligaments and rotator cuff tears(O)(R)(R)(R)
Kidney and bladderAssessment and treatment of the kidney, adrenal gland and bladder(O)(R)(R)(R)
Male reproductive systemAssessment and treatment of the male reproductive system including prostate cancer, circumcision and vasectomy(O)(R)(R)(R)
Digestive systemAssessment and treatment of the digestive system including the oesophagus, stomach, gallbladder, pancreas, spleen, etc.(O)(R)(R)(R)
Hernia and appendixAssessment and treatment of the hernia or appendicitis not including the digestive conditions(O)(R)(R)(R)
Gastrointestinal endoscopyAssessment and treatment of the internal parts of the gastrointestinal system using an endoscope such as colonoscopy and gastroscopy(O)(R)(R)(R)
GynaecologyAssessment and treatment of the female reproductive system including cervical cancer, polycystic ovaries and endometriosis(O)(R)(R)(R)
Miscarriage and termination of pregnancyTreatments and procedures for miscarriage or termination of pregnancy(O)(R)(R)(R)
Chemotherapy, radiotherapy & immunotherapy for cancerHospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours but not including surgical treatment of cancer (which is listed under each relevant body system)(O)(R)(R)(R)
Pain managementTreatments for pain that does not require the insertion or surgical management of a device(O)(R)(R)(R)
SkinHospital treatments for skin-related conditions and nails such as melanoma(O)(R)(R)(R)
Breast surgery (medically necessary)Assessment and treatment of the breast disorders and associated lymph nodes including reconstruction following a preventative mastectomy(O)(R)(R)(R)
Diabetes management (excluding insulin pumps)Assessment and treatment of diabetes such as stabilisation of hypo or hyperglycaemia(O)(R)(R)(R)
Heart and vascular systemAssessment and treatment of the heart-related condition and vascular system such as heart attack and removal of plaque from arterial walls(O)(O)(R)(R)
Lung and chestAssessment and treatment of the lung-related conditions, mediastinum and chest such as lung cancer, pneumonia and trauma to the chest(O)(O)(R)(R)
BloodAssessment and treatment of blood-related conditions such as blood clotting disorders(O)(O)(R)(R)
Back, neck and spineAssessment and treatment of the back, neck and spinal column including spinal fusion(O)(O)(R)(R)
Plastic and reconstructive surgery (medically necessary)Assessment and treatment of any physical deformity from an illness, accident, or congenital such as skin graft for burns(O)(O)(R)(R)
Dental surgerySurgical procedures to the teeth and gums such as dental implant surgery and removal of wisdom teeth(O)(O)(R)(R)
Podiatric surgery (by a registered podiatric surgeon)Assessment and treatment of the foot and ankle but limited cover for hospital accommodation and a prosthesis(O)(O)(R)(R)
Implantation of hearing devicesTreatment of hearing loss using a prosthetic hearing device(O)(O)(R)(R)
CataractsThe removal procedure of cataract and replacement with an artificial lens(O)(O)(O)(R)
Joint replacementsSurgical procedures for joint replacements including revisions, resurfacing, partial replacements and removal of prostheses not including joint or spinal fusions(O)(O)(O)(R)
Dialysis for chronic kidney failureDialysis treatment for chronic kidney failure such as peritoneal dialysis(O)(O)(O)(R)
Pregnancy and birthAssessment and treatment of conditions related to pregnancy and childbirth but not including miscarriage or fertility treatments(O)(O)(O)(R)
Assisted reproductive servicesFertility treatments to assist in becoming pregnant including procedures such as retrieval of eggs/sperm, IVF, GIFT, etc.(O)(O)(O)(R)
Weight loss surgeryHospital procedures to surgically reduce a person’s weight and remove excess skin(O)(O)(O)(R)
Insulin pumpsProvision and replacement of insulin pumps for diabetes patients(O)(O)(O)(R)
Pain management deviceImplantation, replacement or other surgical management of a device to alleviate pain such as an infusion pump(O)(O)(O)(R)
Sleep studiesAssessment and treatment of sleep patterns and anomalies such as sleep apnoea and snoring(O)(O)(O)(R)

Extras and Ambulance Covers

Extras covers are almost completely up to each insurer in terms of the services they offer. They are often additional services and benefits that do not require hospital treatments or admissions such as physiotherapy, dental checkups, regular optical needs (glasses and contacts), and more. They sometimes also cover the cost of the medications which are not included in Medicare’s Pharmaceutical Benefits Scheme (PBS).

Ambulance covers help reduce out-of-pocket costs of using emergency ambulance services. Queensland and Tasmania provide free ambulance services and thus their residents do not need to get ambulance covers. However, for the rest of Australians, it is recommended that they get ambulance covers to help them during unexpected, urgent medical crises. Some hospital covers include ambulance services and some offer ambulance covers separately.

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