All hospital products will be renamed under the product tiers of Gold, Silver, Bronze and Basic from April 1, 2019.
This is a regulatory change that will enable consumers to more easily compare products across health funds and shop around for the best deal.
To understand the tiers - click here.
Top cover, includes cover for all 38 clinical categories.
Silver: Mid-level cover, some exclusions apply.
Bronze: Mid-level cover, more exclusions will apply.
Basic: Basic cover with minimal cover.
The new classification sets minimum standard categories that must be covered under each tier, however the reforms allow private health insurers to oﬀer additional coverage under each tier. As a result, health funds can use the term “plus” or “+” when more than the minimum required services for a particular tier is covered.
The tiers will help members understand what they are covered for and will improve the ability to compare products.
If a policy covers a certain clinical category, then it must cover everything listed in it, not only some procedures.
This is an area that has caused confusion in the past where some heart procedures were covered and some were not.
The clinical categories are based on the Medicare Benefits Schedule and St.LukesHealth can assist if you are unsure what you are covered for.
Restrictions and Exclusions
Under the new hospital treatment product tiers, health insurers can oﬀer restricted cover for some clinical categories.
These categories are rehabilitation, hospital psychiatric services and palliative care and may be oﬀered on a restricted cover basis in Basic, Bronze and Silver Product tiers. No restricted cover is allowed in the Gold tier.
Restricted cover is allowed in the other clinical categories but if a health insurer chooses to do this the product tier will be shown as a Basic tier.
To provide some clarity around restrictions and exclusions, we have included an explanation.
A policy with restrictions means that the member agrees to receive only limited benefits for certain services.
For example, if your policy restricts hip replacements, you will be covered for this as a private patient in a public hospital, however not necessarily in a private room. Your health fund will only pay a minimum benefit towards your accommodation fee and will not pay benefit towards theatre fees in a private hospital. This means you may have large out-of-pocket costs.
A policy with exclusions means the member agrees not to be covered for certain services. For example, if your policy excludes cardiac services you will not be covered in either a private hospital or in a public hospital (as a private patient) and your health fund will not pay any benefit towards your hospital or medical costs.
Prior to April 1, 2019, the maximum excess a health fund could oﬀer on a product that was exempt for Medicare Levy Surcharge was $500 for singles or $1000 for couple and families. Under the new changes, health insurers have the option to allow people to increase their excess to $750 for singles and $1500 for couples and family.
Find out more about the Australian Government Health Insurance Reforms, here