Health Insurance Reforms 2019: What do I need to know about the new clinical categories?

From 1 April, 2019 a new tiered system for private hospital cover will start rolling out under the Federal Government’s health insurance reforms. Insurers will have until 1 April, 2020 to classify their private hospital policies into four major tiers – Gold, Silver, Bronze and Basic.

Insurers may also choose to offer additional cover under the Basic, Bronze and Silver categories to meet the needs of their consumers. These upgraded policies can feature the name of the category along with the word plus or a plus sign, such as Basic Plus or Basic +.

Under these reforms, policies will be categorised based on each tier’s minimum coverage requirements for hospital treatments. These treatments have been standardised into 38 clinical categories.

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What are the clinical categories?

According to the Department of Health, hospital treatments will be referred to in a standard way across health insurance platforms under a new list of clinical categories. Insurers will need to adopt these standard definitions for treatments under the new reforms, which are intended to make private health insurance easier to understand for consumers and encourage more young people to take up health insurance.

Below is a breakdown of the 38 clinical categories and where they fall under the new tiered private hospital insurance system, as outlined by the Department of Health.


Basic Tier

clinical category basic

Basic policies provide restricted cover for three hospital treatment categories as a minimum requirement. Restricted cover means insurers pay a limited amount towards these treatments and there may be out-of-pocket expenses for policy holders.

The categories under the Basic tier are:

Rehabilitation

Physical rehabilitation relating to surgery or illness, such as inpatient and admitted day patient rehabilitation, stroke recovery or cardiac rehabilitation.

Hospital psychiatric services

Treatment for the care of patients with psychiatric, mental, addiction or behavioural disorders, such as addiction therapy, schizophrenia, depression or eating disorders.

Palliative care

Treatment with the intent of providing quality of life for a patient with a terminal illness, including treatment to alleviate or manage pain.


Bronze Tier

clinical category bronze

The Bronze tier of hospital cover includes the same minimum requirements as the Basic tier, but with 18 additional treatment categories, which must be covered without any restrictions.

These 18 categories are:

Brain and nervous system

Investigation and treatment of conditions linked to the brain, spinal cord and peripheral nervous system, such as stroke, epilepsy and Parkinson’s disease.

Eye (not cataracts)

Investigation and treatment of conditions related to the eye and the eye socket, such as eye infections, retinal detachment or trauma to the eye.

Ear, nose and throat

Investigation and treatment of conditions linked to the ear (including middle ear), nose, throat, thyroid, parathyroid, larynx, lymph nodes and related areas of the head and neck. This category includes surgery for things like sinus issues or throat cancer.

Tonsils, adenoids and grommets

Treatment of conditions connected to the tonsils or adenoids and insertion or removal of grommets.

Bone, joint and muscle

Investigation and treatment of diseases, disorders and injuries of the musculoskeletal system, such as fractures, bone spurs, joint fusion and bone cancer.

Joint reconstructions

Surgery for joint reconstructions, such as for torn tendons and damaged ligaments. Joint replacements are a separate category only included as a minimum requirement under Gold tier policies.

Kidney and bladder

Investigation and treatment of conditions related to the kidney, adrenal gland and bladder, such as kidney stones and incontinence. Note that dialysis for chronic kidney failure is a separate category which falls under the Gold tier.

Male reproductive system

Investigation and treatment of conditions linked to the male reproductive system including treatments of the prostate and circumcision.

Digestive system

Investigation and treatment of conditions of the digestive system, including the oesophagus, stomach, gall bladder, pancreas, spleen, liver and bowel, such as gall stones or irritable bowel syndrome.

Hernia and appendix

Investigation and treatment of a hernia or appendicitis.

Gastrointestinal endoscopy

Diagnosis, investigation and treatment of issues within the internal parts of the gastrointestinal system using an endoscope, such as a colonoscopy or gastroscopy.

Gynaecology

Investigation and treatment of conditions connected to the female reproductive system, such as endometriosis or polycystic ovaries. Bear in mind that this does not include assisted reproductive services or pregnancy and birth treatment, which are both separate categories under the Gold tier.

Miscarriage and termination of pregnancy

Investigation and treatment of a miscarriage or for termination of pregnancy.

Chemotherapy, radiotherapy and immunotherapy for cancer

Hospital treatment for chemotherapy, radiotherapy and immunotherapy for the treatment of cancer or benign tumours. This category doesn’t include cancer surgery, which is listed separately under each body part.

Pain management

Treatment for pain management that does not require the insertion or surgical management of a device, such as treatment of nerve pain and chest pain due to cancer by injection of a nerve block. If your pain management requires the insertion or surgical management of a device, the Department of Health advises that it will fall under a separate category within the Gold tier.

Skin

Investigation and treatment of skin- or nail-related conditions, including the removal of foreign bodies and plastic surgery that is medically necessary and related to the skin condition. For example, melanoma surgery, minor wound repair or removal of abscesses.

Breast surgery (medically necessary)

Investigation and treatment of breast disorders and associated lymph nodes, and reconstruction and/or reduction following breast surgery or a preventative mastectomy.

Diabetes management (excluding insulin pumps)

Investigation and management of diabetes, such as stabilisation of hypo- or hyper-glycaemia. Insulin pumps are covered by a separate category that sits within the Gold tier.


Silver Tier

clinical categories silver

The Silver tier of hospital cover includes the same minimum requirements as the Bronze tier, but with eight additional treatment categories.

These eight categories are:

Heart and vascular system

Investigation and treatment of heart and vascular system-related conditions such as heart failure and heart attack, varicose veins and plaque on arterial walls.

Lung and chest

Investigation and treatment of conditions relating to the lungs, mediastinum and chest-related conditions,  including lung cancer and respiratory disorders such as asthma or pneumonia.

Blood

Investigation and treatment of blood-related conditions, such as blood clotting disorders. This includes bone marrow transplants.

Back, neck and spine

Investigation and treatment of conditions linked to the back, neck and spinal column , such as sciatica, prolapsed or herniated discs and spine curvature disorders. Treatment could include spinal fusion.

Plastic and reconstructive surgery (medically necessary)

Investigation and medically necessary treatment of any physical deformity, whether present at birth or acquired from an illness or accident, .

Dental surgery

Treatment for surgery to the teeth and gums, such as dental implants or to remove wisdom teeth.

Podiatric surgery

Investigation and treatment of conditions affecting the foot and/or ankle, provided by a registered podiatric surgeon. This cover is limited to accommodation expenses and the cost of a prosthesis as set out by the law. Insurers are not required to pay for other costs such as the surgeon’s fee.

Implantation of hearing devices

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


Gold Tier

clinical categories gold

The Gold tier of hospital cover includes the same minimum requirements as the Silver tier, but with nine additional treatment categories. These nine categories are:

Cataracts

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

Joint replacements

Treatment for surgery for joint replacements, including revisions, resurfacing, partial replacements and removal of prostheses, such as the replacement of a shoulder, hip, knee or ankle joint.

Dialysis for chronic kidney failure

Dialysis treatment for chronic kidney failure, including peritoneal dialysis and haemodialysis.

Pregnancy and birth

Investigation and treatment of conditions associated with pregnancy and child birth. Bear in mind that this does not include medical treatment for the baby, which is instead categorized based on their particular condition.

Assisted reproductive services

Hospital treatment for fertility treatments or procedures, such as IVF and the retrieval of eggs or sperm.

Weight-loss surgery

Treatment for surgery that is designed to reduce a person’s weight, such as gastric banding and gastric bypass surgery. This category also includes surgery to remove excess skin due to weight loss and reversal of bariatric procedures.

Insulin pumps

Hospital-based provision and replacement of insulin pumps for treatment of diabetes.

Pain management with device

Hospital-based implantation, replacement or other surgical management of a device required for the treatment of pain.

Sleep studies

Investigation of disturbed sleep patterns and anomalies, such as sleep apnoea and snoring.


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

A detailed breakdown of the minimum coverage requirements for each tier can be found under the following – Basic, Bronze, Silver and Gold.

Cover image source: Minerva Studio

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