Gold tier insurance cover will be needed for rheumatology treatments

Patients will need the most expensive Gold tier of private health insurance to access some treatments for rheumatological and musculoskeletal conditions, according to a draft guide provided by the Department of Health

Under a new four-tier grading system that comes into effect from 1 April 2019, hospital admissions for chronic back pain, spinal fusion and some joint replacements will be a minimum requirement only for the Gold tier health insurance policies.

The categories are explained in a new guide to hospital services that will be available under Basic, Bronze, Silver and Gold tiers of private health insurance policies.

According to the table, Gold tier cover will be required for admission for surgery for joint replacements, including revisions, resurfacing, partial replacements and removal of prostheses, and spinal fusions for conditions other than scoliosis.  Examples cited include  replacement of shoulder, wrist, finger, hip, knee, ankle, or toe joint, spinal disc replacement.

Other spinal treatments, including spinal fusions for scoliosis, are included under the “Back, neck and spine” category in the Silver tier.

Joint fusions are included under bone, joint and muscle category in Bronze tier policies.

Hospital admission for chronic pain – including chronic back pain – is also only covered as a minimum requirement in Gold tier policies.

The Silver tier has a minimum requirement to cover admissions for the investigation and treatment for the back, neck and spine, such as sciatica, spinal cord tumours, prolapsed or herniated disc, scoliosis and lordosis (including spinal fusion).

Bronze tier policies have a minimum requirement to cover admission for investigation and joint reconstruction procedures such as torn tendons, rotator cuff tears and damaged ligaments. Bronze tier policies will also cover  the investigation and treatment of bone, joint and muscle conditions including carpal tunnel, fractures, hand surgery, bone spurs, osteomyelitis and bone cancer.

‘Basic’ tier health insurance  – which the AMA has described as junk policies – are only required to provide restricted cover for palliative care, hospital psychiatric services and admission for physical rehabilitation for a patient recovering from surgery or illness. However insurers may choose to offer additional services on a restricted or unrestricted basis in their Basic tier policies.

Federal Minister for Health Greg Hunt said the new system was designed to give consumers clearer information on what services will be available to them from the policy they buy.

“Our changes are focused on helping consumers understand what is on offer, giving them the opportunity to shop around for the best policy that suits their needs, at the best price.

“Standard clinical categories will be mandated, as well as standard terms for medical treatments,” he added.

Insurers will also be able to offer cover for clinical categories in addition to those listed as the minimum requirements for the Silver, Bronze, Basic product tiers, in which case the products may be named [Silver, Bronze, Basic] Plus (+).

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