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How does Hospital Cover work?

Reviewed and updated 20 April 2023

The Australian Government has designated 38 clinical categories for Hospital Cover:

  1. Rehabilitation
  2. Hospital Psychiatric Services
  3. Palliative Care
  4. Brain and Nervous System
  5. Eye (not cataracts)
  6. Ear, Nose and Throat
  7. Tonsils, Adenoids and Grommets
  8. Bone, Joint and Muscle
  9. Joint Reconstructions
  10. Kidney and Bladder
  11. Male Reproductive System
  12. Digestive System
  13. Hernia and Appendix
  14. Gastrointestinal Endoscopy
  15. Gynaecology
  16. Miscarriage and Termination of Pregnancy
  17. Chemotherapy, Radiotherapy and Immunotherapy for Cancer
  18. Pain Management
  19. Skin
  20. Breast Surgery (medically necessary)
  21. Diabetes Management (excluding insulin pumps)
  22. Heart and Vascular System
  23. Lung and Chest
  24. Blood
  25. Back, Neck and Spine
  26. Plastic and Reconstructive Surgery (medically necessary)
  27. Dental Surgery
  28. Podiatric Surgery (provided by a registered Podiatric Surgeon)
  29. Implantation of Hearing Devices
  30. Cataracts
  31. Joint Replacement
  32. Dialysis for Chronic Kidney Failure
  33. Pregnancy and Birth
  34. Assisted Reproductive Services
  35. Weight Loss Surgery
  36. Insulin Pumps
  37. Pain Management with Device
  38. Sleep studies.

The Government also decides which treatments must be included under each clinical category. Insurers are not allowed to vary or exclude those treatments from their cover.

When you get a quote for Hospital Cover, you cannot choose the clinical categories you want cover for.

Instead, since 1 April 2020, you choose a policy from 4 product tiers: 

  • Basic
  • Bronze
  • Silver
  • Gold.

The Government decides which clinical categories fall into each tier. When you buy a Hospital Cover policy, you know exactly what clinical categories and treatments are included:

Level Treatments included
Basic Hospital Cover 3 of 38
Bronze Hospital Cover 21 of 38
Silver Hospital Cover 29 of 38
Gold Hospital Cover 38 of 38

The Government uses this system of Hospital Cover tiers to make it easier for you to compare policies from different insurers.

One limitation is you have to pay for treatments in clinical categories you will never use:

Bert takes out Gold Hospital Cover but this includes some treatments he is unlikely to need.

Bert is 25. He decides to purchase Gold Hospital Cover because, after reviewing the list of 38 clinical categories, he wants cover for joint replacements. He discovers only Gold Hospital Cover includes this clinical category. However, if he takes out Gold Cover, he will also be paying for treatments in clinical categories he is unlikely to need, including: 
– assisted reproductive services
– pregnancy and birth
– weight loss surgery
– sleep studies
– insulin pumps.

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