How does Hospital Cover work?

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:

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: