Hospital cover: compare Basic, Bronze, Silver and Gold

What hospital cover pays for

Depending on the policy and the clinical categories it covers, hospital cover pays some or all of these costs when you're admitted as a private patient:

• Hospital accommodation, including meals, in a shared or private room depending on the policy.
• Theatre costs for your operation or procedure.
• Your in-hospital doctors and specialists: Medicare pays 75% of the Medicare Benefits Schedule fee and your fund at least 25%. Fees above the schedule are a gap unless your doctor uses your fund's gap scheme.
• Medical devices used in your treatment, such as an implanted prosthesis, which appear on the hospital's bill.
• A second-tier default benefit if the hospital has no agreement with your fund but has been assessed as eligible.

What each hospital tier must cover

The government groups hospital treatment into 38 clinical categories, such as 'bone, joint and muscle' or 'heart and vascular system'. A policy's tier depends on which of those categories it covers in full. If a policy covers a category, it must cover everything in that category, not just some of it.

Basic must include rehabilitation, hospital psychiatric services and palliative care, and may cover those three on a restricted basis. Bronze adds 18 common categories, including joint reconstructions, hernia and appendix, gynaecology, and chemotherapy for cancer. Silver adds heart and vascular, lung and chest, back, neck and spine, dental surgery and hearing implants. Only Gold must cover cataracts, joint replacements, dialysis, pregnancy and birth, assisted reproduction, weight loss surgery, insulin pumps, pain management with a device and sleep studies.

Basic hospital cover: what it covers and who it suits

Basic is the lowest hospital tier. A Basic policy must cover only three clinical categories: rehabilitation, hospital psychiatric services and palliative care, and it may cover even those on a restricted basis. A Basic Plus policy adds some of the other categories, chosen by the fund; some Basic policies cover a wider range of treatment but only after an accident.

It's the cheapest hospital cover that counts for the Medicare Levy Surcharge and Lifetime Health Cover, provided the excess is no more than $750 a year on a singles policy or $1,500 on any other. In the Government's data for singles policies open in NSW at 1 October 2026, Basic had the lowest median premium of any hospital tier, followed by Basic Plus and then Bronze.

That makes Basic suit two groups: people earning over the surcharge threshold who mainly want to avoid it, and people approaching the 1 July after their 31st birthday who want to lock in no Lifetime Health Cover loading. It isn't cover for planned surgery: for joint reconstructions, hernias or cancer treatment you need at least Bronze.

Gold vs Silver vs Bronze: what changes at each tier

Each step up the tiers adds a fixed set of clinical categories. Basic to Bronze adds 18, including joint reconstructions, hernia and appendix, gynaecology, and chemotherapy, radiotherapy and immunotherapy for cancer. Bronze to Silver adds 8: heart and vascular, lung and chest, blood, back, neck and spine, medically necessary plastic and reconstructive surgery, dental surgery, podiatric surgery and hearing device implants.

Silver to Gold adds the last 9: cataracts, joint replacements, dialysis, pregnancy and birth, assisted reproduction, weight loss surgery, insulin pumps, pain management with a device and sleep studies. Gold must also cover rehabilitation, psychiatric and palliative care without restriction. The difference between Silver and Gold is mostly the treatments people need later in life or when starting a family.

Plus policies: why two Silver policies can differ

A policy that meets a tier's minimum and adds more categories can be sold as Basic Plus, Bronze Plus or Silver Plus. A Silver Plus policy might add joint replacements or pregnancy, for example, while another fund's Silver Plus adds something else entirely. The tier name tells you the floor, not the ceiling.

The practical rule is to list the categories you actually care about, then check each one on the policy's Private Health Information Statement. Every insurer must publish one for every policy, and privatehealth.gov.au lets you search and compare them across all funds.

Restricted cover versus excluded cover

An excluded category is not covered at all, whether you are treated in a public or a private hospital. A restricted category is partly covered: you are covered as a private patient in a public hospital, but in a private hospital your fund pays only a small part of the accommodation cost and you pay the rest.

Restrictions matter most on Basic and Bronze policies, where rehabilitation, psychiatric care and palliative care are often restricted. If mental health treatment in a private hospital is important to you, check that the policy lists hospital psychiatric services as covered, not restricted.

Excess and co-payments: trading premium for out-of-pocket cost

An excess is the amount you agree to pay towards a hospital admission before your fund pays. A co-payment is a set amount per day in hospital, usually capped per stay. Both lower your premium, and both only cost you anything if you are admitted.

Check two details before you choose. First, whether the excess applies per person or per policy each year, and whether it is waived for children. Second, if you hold hospital cover to avoid the Medicare Levy Surcharge, the yearly excess must be no more than $750 for singles or $1,500 for couples and families (limits in place since 1 April 2019).

The gap: what hospital cover does not remove

Doctors set their own fees and many charge above the Medicare Benefits Schedule fee. Medicare pays 75% of the schedule fee and your fund at least 25%, so anything above the schedule fee is yours to pay unless your fund has a gap-cover arrangement with that doctor. Surgeons, anaesthetists and assistant surgeons each bill separately. Outside hospital, Medicare pays 100% of the schedule fee for GP visits and 85% for most other services, such as specialist consultations, according to Services Australia; hospital cover doesn't pay towards those.

Before a planned admission, ask each doctor for the MBS item numbers and a written estimate, then ask your fund what it will pay for those items. The government's Medical Costs Finder shows what people typically pay for common procedures. If a private hospital has no agreement with your fund, you can still receive a benefit, called a second-tier default benefit, provided the hospital has been assessed as eligible for it. Check before you book, because the hospital may charge more than your fund pays.

Is hospital cover worth it in Australia?

It depends on your income, your age and how much you value choosing your doctor and the timing of planned surgery. Emergency and public hospital care is available through Medicare either way. Two government rules can tip the arithmetic.

The Medicare Levy Surcharge: a single person with an income for surcharge purposes of $130,000 in 2026–27 and no hospital cover pays 1.25% of it, or $1,625 for the year, if all of it is taxable income and fringe benefits. If a qualifying hospital policy costs less than that after the rebate, holding it is cheaper than not. Our Medicare Levy Surcharge calculator works out your own break-even figure.

Lifetime Health Cover loading: someone who is 40 on the 1 July before they first take out hospital cover pays a 20% loading on the hospital premium, for ten years. Taking cover before the 1 July after your 31st birthday avoids it.

Hospital-only cover vs hospital and extras

Hospital-only cover pays nothing towards dental, optical, physio or other services outside hospital; for those you need extras. If you claim extras every year, compare a combined policy with hospital cover at one fund and extras at another: see hospital and extras cover for how the two halves work together.

Waiting periods on hospital cover

The law sets the maximum waits, and they apply when you first join and to anything new when you upgrade. If you switch funds to the same or a lower level of cover, your new fund must recognise the waits you have already served.

What hospital cover does not pay for

Hospital cover does not pay for GP visits, specialist consultations in their rooms, or scans and blood tests done outside an admission; Medicare covers those. It does not pay for dental, optical or physio outside hospital, which is extras cover. Emergency ambulance is included in many hospital policies but not all, and some states cover residents anyway, so check it separately.