New health insurance tiers aim to make health insurance simpler for consumers.
The Australian government provided some clarity surrounding the much-anticipated health insurance tiers, which will come into effect from 1 April 2019. The new classification system, which has been on the table since the government announced a range of reforms in October 2017, aims to provide consumers with a simplified tier structure for policies: Gold, Silver, Bronze and Basic.
The four-tiered system will affect all of the existing 70,000 private health insurance policies in Australia. Along with the new health insurance tiers, the government has also promised improved coverage for women.
What does each tier cover?
While consumers will have to wait until early 2019 to find out how new policies will be categorised by their health fund, you can expect the following tiers to cover the following procedures:
What does the Basic tier health insurance cover?
The Basic tier of cover only entitles consumers to three treatments as a minimum requirement. However, the three treatments below may be offered on a restricted basis.
- Hospital psychiatric services
- Palliative care
What does the Bronze tier health insurance cover?
On the Bronze tier, consumers can expect the same minimum requirements as the Basic tier. Rehabilitation, hospital psychiatric services and palliative care still may be offered on a restricted basis. In addition to what is covered by Basic policies, Bronze policies include cover for the following:
- Ear, nose and throat
- Tonsils, adenoids and grommets
- Bone, joint and muscle
- Joint reconstructions
- Kidney and bladder
- Male reproductive system
- Digestive system
- Hernia and appendix
- Gastrointestinal endoscopy
- Miscarriage and termination of pregnancy
- Chemotherapy, radiotherapy and immunotherapy for cancer
- Breast surgery (medically necessary)
What does the Silver tier health insurance cover?
On the Silver tier, consumers can expect the same minimum requirements as the Bronze tier. The Silver tier may also offer rehabilitation, hospital psychiatric services and palliative care on a restricted basis just like the Basic and Bronze tiers. In addition to the services that the Basic and Bronze policies cover, Silver policies also include cover for the following:
- Heart, lung and vascular system
- Back, neck and spine
- Plastic and reconstructive surgery (medically necessary)
- Dental surgery
- Podiatric surgery (provided by an accredited podiatric surgeon)
- Implantation of hearing devices
What does the Gold tier health insurance cover?
The Gold tier is the only tier that offers cover for rehabilitation, hospital psychiatric services and palliative care without restrictions. In addition to the services that the three previous tiers cover, the Gold tier provides coverage for the following:
- Joint replacement and spinal fusion
- Dialysis for kidney disease
- Pregnancy, birth and neonates
- Assisted reproductive services
- Weight loss surgery
- Insulin pumps
- Chronic pain
- Sleep studies
What else is changing with these reforms?
The major beneficiaries of these reforms will be Australian women, who for the first time will benefit from gynaecological services, ovarian and breast cancer treatment and breast reconstruction under the Silver and Bronze categories. These reforms aim to amend the "disparity in the past between coverage of men and women for different types of cancers."
Why is Australia getting a tiered health insurance?
The government made these changes so that consumers have a "no surprise" experience with their health insurance, meaning that consumers know exactly what they are in for at each tier of cover.
According to a governmental release, "standard clinical categories will be mandated, as well as standard terms for medical treatments" for each tier. This will mean you can go down a list, check off items you do and don't want cover for and make a decision. Additionally, standardising the terms for the treatments will cut out the guesswork consumers have to do when comparing policies, making it easier to compare apples with apples. All the info will be provided on a single document.
While the government is mandating that policies be split into tiers, there will be some wiggle room for health insurers who choose to offer coverage beyond the minimum mandated standards set out by the legislation. This means that in the lower tiers of cover, the Silver, Bronze and Basic tiers, insurers will be able to offer a premium form of that cover with a Plus (+).
Overview of hospital treatments in Basic, Bronze, Silver and Gold
|Hospital treatments by clinical category||Basic||Bronze||Silver||Gold|
|Hospital psychiatric services|
|Brain and nervous system||RCP|
|Eye (not cataracts)||RCP|
|Ear, nose and throat||RCP|
|Tonsils, adenoids and grommets||RCP|
|Bone, joint and muscle||RCP|
|Kidney and bladder||RCP|
|Male reproductive system||RCP|
|Hernia and appendix||RCP|
|Miscarriage and termination of pregnancy||RCP|
|Chemotherapy, radiotherapy and immunotherapy for cancer||RCP|
|Breast surgery (medically necessary)||RCP|
|Diabetes management (excluding insulin pumps)||RCP|
|Heart and vascular system||RCP|
|Lung and chest||RCP|
|Back, neck and spine||RCP|
|Plastic and reconstructive surgery (medically necessary)||RCP|
|Podiatric surgery (provided by a registered podiatric surgeon)||RCP|
|Implantation of hearing devices||RCP|
|Dialysis for chronic kidney failure||RCP|
|Pregnancy and birth||RCP|
|Assisted reproductive services||RCP|
|Weight loss surgery||RCP|
|Pain management with device||RCP|