Gold Tier Private Health Insurance: What does it cover?


The new tiered system of private hospital insurance will begin rolling out from 1 April, 2019, with every insurer required to implement it by 1 April, 2020. This system classifies hospital policies into four tiers – Gold, Silver, Bronze and Basic. Here is a break down of what the Gold tier covers.

The tiered health insurance system is part of a raft of Federal Government reforms aimed at simplifying health insurance policies for Australians. According to the Federal Government, many consumers find hospital insurance complex and hard to understand. The Government hopes the reforms will make it easier for consumers to compare products and see what each product does and doesn’t offer.

Each tier has different categories of medical treatments and services which products in that particular group must include as a minimum. For example, Silver and Gold policies have to cover dental surgery, while Basic and Bronze policies do not.

Insurers can also choose to offer Plus policies within each tier which include additional coverage on top of the minimum standards required. For example, you could have a Bronze Plus policy that includes dental surgery, which would normally only be available under a Silver policy. As Gold is the top tier of coverage, Gold Plus is not an option.

What is the Gold tier of cover?

Gold policies offer the highest level of hospital cover available, covering you for all 38 of the clinical categories. Because they will cover you for the widest range of services and treatments, Gold policies are likely to be the most expensive policies you can take out.

What hospital cover does the Gold tier include?

On top of providing the same level of cover as Silver policies, Gold policies include an additional nine clinical categories such as cataracts, pregnancy and birth, and joint replacements.

Pregnancy and birth gold tier health insurance
Source: Natalia Deriabina (Shutterstock)

Furthermore, in comparison to the Basic, Bronze and Silver tiers, Gold tier policies must provide unrestricted cover for each category. This includes rehabilitation, hospital psychiatric services and palliative care, which insurers are only required to cover on a restricted basis under their policies in other tiers.

The categories covered under a Gold tier policy are:

Tick Rehabilitation Tick Breast surgery (medically necessary)
Tick Hospital psychiatric services Tick Diabetes management (excluding insulin pumps)
Tick Palliative care Tick Heart and vascular system
Tick Brain and nervous system Tick Lung and chest
Tick Eye (not cataracts) Tick Blood
Tick Ear, nose and throat Tick Back, neck and spine
Tick Tonsils, adenoids and grommets Tick Plastic and reconstructive surgery (medically necessary)
Tick Bone, joint and muscle Tick Dental surgery
Tick Joint reconstructions Tick Podiatric surgery (provided by registered podiatric surgeon)
Tick Kidney and bladder Tick Implantation of hearing device
Tick Male reproductive system Gold tier health insurance Cataracts
Tick Digestive system Gold tier health insurance Joint replacements
Tick Hemia and appendix Gold tier health insurance Dialysis for chronic kidney failure
Tick Gastrointestinal endoscopy Gold tier health insurance Pregnancy and birth
Tick Gynaecology Gold tier health insurance Assisted reproductive services
Tick Miscarriage and termination of pregnancy Gold tier health insurance Weight loss surgery
Tick Chemotherapy, radiotherapy and immunotherapy for cancer Gold tier health insurance Insulin pumps
Tick Pain management Gold tier health insurance Pain management with device
Tick Skin Gold tier health insurance Sleep studies

Gold tier health insurance Indicates the clinical category is a minimum requirement of the Gold tier only.

For a rundown of what sorts of hospital treatments these 38 categories are expected to include, click here.

Who may suit Gold cover?

A Gold tier policy may be worth considering if you are pregnant or trying to get pregnant. If you want to give birth as a private patient, Gold is the only tier that is required to cover you for pregnancy and birth, although it’s possible that some insurers may ultimately decide to create Silver Plus policies with these services included. Additionally, Gold policies will provide coverage if you need assisted reproductive services such as IVF.

Gold policies may also be worth looking into for older Australians or people with chronic illnesses. Notably, the Gold tier is the only one required to cover cataracts, joint replacements and dialysis for chronic kidney failure, which policies from other tiers will not necessarily cover. According to the Australian Commission on Safety and Quality in Health Care, cataract surgery is the most common elective procedure in Australia. Gold tier policies could also be of interest if you have diabetes and need an insulin pump.

If you’re interested in taking out a Gold hospital insurance policy, bear in mind that insurers will have until 1 April, 2020 to implement the tiered system. If you already have private health insurance, it is worth being aware that your insurer may rename your product or add or remove services to fit your product into a different tier of cover. If you’re unsure, it could be worth asking your health fund if, how and when the reforms may impact you.

To find out more about the reform changes, click here.

A breakdown of the minimum coverage requirements for the other tiers can be found under the following – BasicBronze and Silver.

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