Understanding the four health insurance categories – Basic, Bronze, Silver, Gold

Summary

  • Several changes were made to the private health insurance sector in Australia in the year 2019.
  • These changes included introduction of four new tiers of the hospital cover which later became mandatory for all insurers
  • Now, private health covers are classified into gold, silver, bronze or basic categories.

Australia’s private health insurance sector went through a slew of changes in 2019. One of the major changes was the introduction of four new tiers of hospital cover. These tiers began rolling out from 1 April 2019 and were made compulsory from 1 April 2020. Since then, all the hospital policies are classified into gold, silver, bronze or basic across the country.

Gold, silver, bronze, basic product tiers

The government of Australia has introduced reforms that make private health insurance simpler and help people select the insurance cover that suits their requirements most.                                                                                                                                     

The government has advised the private health insurers to classify their private hospital cover into four easy-to-understand tiers: Gold, silver, bronze and basic.  

Services that are not covered  by these tiers are usually based on the minimum standard clinical categories. Clinical categories are nothing but various hospital treatments described in a standard way.

If a particular policy covers a certain clinical category, then it should cover everything described as part of that category – not just a select few things. For example, the category of ‘bone, joint and muscle’ or ‘heart and vascular system’. This makes policies easier to compare.

Now private health insurers will place all policies into one of these tiers – gold, silver, bronze and basic. They will also inform people where their policy is getting placed. People also are required to know and then check if the cover is right for their needs.

The tiers are meant to authorise minimum service coverage requirements, generally reflecting the existing range of health insurance policies.

Also, insurers will always be offering additional coverage above the minimum requirements in basic +, bronze + and silver + product tiers.

All health insurers are expected to introduce the tiers and clinical categories until 1 April every year. 

For more information on Hospital treatment product tiers, one may browse through the health government website for more categories and details.

Who is benefitted?

Hospital covers can be confusing. The bifurcation of products around tiers and clinical categories help people know about the services covered by each type of private hospital cover. This tier system basically makes it easier to shop around and compare different hospital policies to select one that meets an individual or family’s needs.

Restricted and unrestricted categories

Clinical categories can either be restricted or unrestricted. This defines the level of benefits paid for hospital costs like accommodation, operation theatre fee, prosthesis etc. These are generally separate from the doctors’ fee.

For clinical categories listed as ‘restricted’ – insurers pay only a limited amount for private hospital costs, which means people are likely to face substantial out-of-pocket expenses.

For unrestricted categories – Majority of the hospitals and insurers have agreements that people are not required to pay out-of-pocket hospital costs, other than any excess or fixed copayment amount.

Out-of-pocket costs for doctors’ fee may also be payable if a doctor charges more than the Medicare Benefits Schedule fee and the insurer covers only a part of the remaining payment.

Unplanned hospital treatment and getting treated for complications

Complications

If a person is admitted to a hospital for a planned treatment which is included in the policy and thereafter complications arise because of a treatment which is not covered in the policy, the insurer is bound to cover the treatment of that complication as well.

Unplanned treatment

If anyone is admitted to the hospital for a planned treatment which is included in the policy, and during the treatment, doctor finds out that he has another condition that requires urgent treatment, this ‘associated unplanned treatment’ should also be covered by the insurer.

Two or more procedures where one is excluded from the hospital cover policy

According to the new regulations out in 2019, insurers are needed to cover elective processes that are covered by policy, and all related services or complications arising from the procedure. Though, the insurer is not bound to cover any planned elective procedures not on offer as per the policy, even if they are done in the same admission.

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