The guide · card 2 of 6
Gold, Silver, Bronze and Basic: the four hospital tiers
Every hospital policy in Australia is classified as Gold, Silver, Bronze or Basic, and the tier sets the minimum list of clinical categories it must cover. Tiers have been mandatory since 1 April 2020, and a policy that covers more than its tier’s minimum can be called ‘Plus’.
How a policy earns its tier
To carry a tier’s name, a hospital policy has to meet that tier’s minimum requirements: it must include every clinical category required for the tier. Each clinical category is a group of hospital treatments, such as ‘bone, joint and muscle’ or ‘heart and vascular system’, and a policy that covers a category must cover everything in it, not only some things. Everything in the table refers to treatment received as part of a hospital admission.
Four tiers began rolling out from 1 April 2019 and became mandatory from 1 April 2020. Your insurer assigns each policy to a tier and will let you know which one yours is.
Every category, tier by tier
There are 38 clinical categories on the official table. Reading down a column shows what that tier must cover; reading across a row shows the lowest tier where a treatment becomes a requirement.
| Clinical category | Basic | Bronze | Silver | Gold |
|---|---|---|---|---|
| Rehabilitation | Required, may be restricted | Required, may be restricted | Required, may be restricted | Required |
| Hospital psychiatric services | Required, may be restricted | Required, may be restricted | Required, may be restricted | Required |
| Palliative care | Required, may be restricted | Required, may be restricted | Required, may be restricted | Required |
| Brain and nervous system | Optional, may be restricted | Required | Required | Required |
| Eye (not cataracts) | Optional, may be restricted | Required | Required | Required |
| Ear, nose and throat | Optional, may be restricted | Required | Required | Required |
| Tonsils, adenoids and grommets | Optional, may be restricted | Required | Required | Required |
| Bone, joint and muscle | Optional, may be restricted | Required | Required | Required |
| Joint reconstructions | Optional, may be restricted | Required | Required | Required |
| Kidney and bladder | Optional, may be restricted | Required | Required | Required |
| Male reproductive system | Optional, may be restricted | Required | Required | Required |
| Digestive system | Optional, may be restricted | Required | Required | Required |
| Hernia and appendix | Optional, may be restricted | Required | Required | Required |
| Gastrointestinal endoscopy | Optional, may be restricted | Required | Required | Required |
| Gynaecology | Optional, may be restricted | Required | Required | Required |
| Miscarriage and termination of pregnancy | Optional, may be restricted | Required | Required | Required |
| Chemotherapy, radiotherapy and immunotherapy for cancer | Optional, may be restricted | Required | Required | Required |
| Pain management | Optional, may be restricted | Required | Required | Required |
| Skin | Optional, may be restricted | Required | Required | Required |
| Breast surgery (medically necessary) | Optional, may be restricted | Required | Required | Required |
| Diabetes management (excluding insulin pumps) | Optional, may be restricted | Required | Required | Required |
| Heart and vascular system | Optional, may be restricted | Optional | Required | Required |
| Lung and chest | Optional, may be restricted | Optional | Required | Required |
| Blood | Optional, may be restricted | Optional | Required | Required |
| Back, neck and spine | Optional, may be restricted | Optional | Required | Required |
| Plastic and reconstructive surgery (medically necessary) | Optional, may be restricted | Optional | Required | Required |
| Dental surgery | Optional, may be restricted | Optional | Required | Required |
| Podiatric surgery (by a registered podiatric surgeon) | Optional, may be restricted | Optional | Required | Required |
| Implantation of hearing devices | Optional, may be restricted | Optional | Required | Required |
| Cataracts | Optional, may be restricted | Optional | Optional | Required |
| Joint replacements | Optional, may be restricted | Optional | Optional | Required |
| Dialysis for chronic kidney failure | Optional, may be restricted | Optional | Optional | Required |
| Pregnancy and birth | Optional, may be restricted | Optional | Optional | Required |
| Assisted reproductive services | Optional, may be restricted | Optional | Optional | Required |
| Weight loss surgery | Optional, may be restricted | Optional | Optional | Required |
| Insulin pumps | Optional, may be restricted | Optional | Optional | Required |
| Pain management with device | Optional, may be restricted | Optional | Optional | Required |
| Sleep studies | Optional, may be restricted | Optional | Optional | Required |
required for the tier optional, the insurer may add it restricted cover permitted
What each step up adds
Counting the table’s required cells gives the shape of the four tiers: 3 categories for Basic, 21 for Bronze, 29 for Silver and all 38 for Gold.
Basic · 3 required
Rehabilitation, hospital psychiatric services and palliative care, which may be covered on a restricted basis. Every other category is optional and may also be restricted.
Bronze · adds 18
Brain and nervous system; eye (not cataracts); 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; gynaecology; miscarriage and termination of pregnancy; chemotherapy, radiotherapy and immunotherapy for cancer; pain management; skin; breast surgery (medically necessary); diabetes management (excluding insulin pumps).
Silver · adds 8
Heart and vascular system; lung and chest; blood; back, neck and spine; plastic and reconstructive surgery (medically necessary); dental surgery; podiatric surgery; implantation of hearing devices.
Gold · adds 9
Cataracts; joint replacements; dialysis for chronic kidney failure; pregnancy and birth; assisted reproductive services; weight loss surgery; insulin pumps; pain management with device; sleep studies.
A policy that meets a tier’s minimum and adds more cover can be called a ‘Plus’ policy, such as Bronze Plus or Silver Plus. The name tells you the floor, not the ceiling, so two Bronze Plus policies can differ: the extra categories are listed on each policy’s information statement.
What ‘restricted’ means
Where the table allows restricted cover, insurers may offer that category on a restricted basis. A restricted benefit means you are partly covered for hospital costs as a private patient in a public hospital, and you may face significant expenses in a private room or a private hospital. Ask the insurer and the hospital for details before a planned admission.
When treatment crosses a category line
Hospital stays do not always stay inside one category. The rules deal with three situations.
A complication
If you are admitted for planned treatment your policy covers and a complication arises outside its scope, the insurer is required to cover treating the complication. The official example: someone admitted for surgery on a digestive illness who develops an acute arrhythmia during that episode of treatment is covered for the cardiologist and cardioversion, even if the policy does not otherwise cover heart and vascular system.
An unplanned, urgent condition
If, during a covered admission, your doctor finds another condition that needs urgent treatment, that ‘associated unplanned treatment’ must be covered, as long as it is provided in the same episode of care and the treating practitioner considers it medically urgent and necessary.
Two planned procedures, one not covered
The insurer does not have to cover a planned elective procedure your policy excludes, even in the same admission. The official example is a Bronze policy holder who has their tonsils removed and chooses dental surgery in the same stay: only the tonsillectomy and its associated services are covered.
Where to look a category up
The tier page on privatehealth.gov.au links to the full category definitions, including the Medicare Benefits Schedule item numbers in each one. Tiers describe hospital cover only; how they sit beside extras is on the first card.