New Health Insurance clinical categories 2019

Part of the Private Health Insurance reforms that rolled out this April included the new standardised Clinical Category.

Before this reform, health funds termed medical conditions differently across private health. This made an already complex subject even harder to understand. To help Australians understand what their policy covers and to help them compare their cover, there is now one set list of medical services.

The clinical category is a list of all the medical services and treatments that you can purchase hospital cover for through your health fund.

If a policy covers certain categories like heart and vascular, it needs to cover every condition under the scope of that service on the Medicare Benefits Schedule, and not just a few. Always ask your health fund if you want to be covered for a certain medical treatment. Even though the list has been standardized, it can still be a bit tricky, so we recommend that you always discuss medical treatments with your insurer. Note that some MBS items can be found in more than one category.

Health Deal has put together a list of some of the clinical categories, and what may be covered under each treatment or procedure.

In-patient and admitted day patient rehabilitation following an illness like a stroke or cardiac related attack.

In-hospital treatment for psychoses such as schizophrenia, mood and eating disorders and therapy for addiction.

In-hospital care for a patient with a terminal illness through treatments such as managing pain.

In-hospital treatment for fertility treatments such as egg and sperm lifting, In Vitro Fertilisation (IVF) and Gamete Intra-fallopian Transfer (GIFT).

In-hospital treatment for the assessment and treatment of the back, neck and spinal column. These include treatments such as spinal disc replacement, scoliosis, sciatica, and herniated disc.

In-hospital treatment for the assessment and treatment of blood-related conditions such as haemophilia and bone marrow transplants.

Hospital treatment for musculoskeletal disorders, injuries, and diseases. These include carpal tunnel, joint fusion, and fractures.

In-hospital treatment for brain and spinal cord-related conditions such as stroke, Parkinson’s disease, head injuries and epilepsy.

Treatment for breast disorders and associated lymph nodes and reconstructive surgery following a mastectomy.

In-hospital treatment for cataract surgery.

Cancer treatments that do not involve surgery such as chemotherapy, immunotherapy, and radiotherapy.

Surgery for the removal of wisdom teeth and dental implant surgery.

Stabilisation of hypo- or hyper-glycaemia, contour problems as a result of insulin injections.

In-hospital dialysis treatment such as peritoneal dialysis and haemodialysis.

In-hospital treatment for the assessment and treatment of the digestive system for conditions such as oesophageal cancer, irritable bowel syndrome, gall stones and haemorrhoids.

In-hospital treatment for conditions such as a damaged ear drum, sinus surgery, removal of foreign bodies, stapedectomy and throat cancer.

In-hospital treatment for eye-related conditions such as retinal detachment, eye infections, and tear duct conditions.

In-hospital endoscopic treatment for conditions related to the inner gastrointestinal system such as colonoscopies and gastroscopy.

In-hospital treatment for conditions related to the female reproductive system such as cervical cancer, endometriosis, and polycystic ovaries.

In-hospital treatment for conditions related to the heart and vascular system such as heart attack, heart failure, varicose veins and removal of plaque from artery walls.

In-hospital treatment for appendicitis and hernia.

In-hospital treatment for the correction of hearing loss, including the implantation of a hearing device.

In-hospital treatment for the distribution and replacement of insulin pumps for diabetes management.

In-hospital treatment for joint replacement surgery including revisions, resurfacing, partial replacements and removal of prosthesis.

In-hospital treatment for joint reconstruction surgery such as torn tendons and ligaments.

In-hospital treatment for the assessment and treatment of bladder and kidney-related conditions. For example, kidney stones, incontinence, and adrenal gland tumour.

In-hospital treatment for the assessment and treatment of lung-related conditions, mediastinum, and chest. These conditions include lung cancer and respiratory conditions like asthma and pneumonia.

In-hospital treatment for the assessment and treatment of conditions relating to the male reproductive system including prostate cancer, male sterilisation, and circumcision.

Termination of pregnancy and treatment for miscarriage.

In-hospital treatment for pain management that does not involve a device or surgery. This is for conditions such as nerve and chest pain due to cancer by injection of a nerve block.

The treatment of pain using a device such as a neurostimulator for back or nerve pain.

In-hospital treatment for burns requiring a graft, cleft palate, club foot and angioma.

In-hospital treatment for foot and ankle related conditions. This includes the cost of accommodation and prosthesis listed under PHI prosthesis list.

In-hospital care for pregnancy and delivery. This treatment only includes the mother as babies will be treated under their relevant conditions.

In-hospital treatment for the removal of foreign bodies and skin and nail-related conditions such as melanoma and abscess.

This includes medically necessary surgery such as minor wound repair.

In-hospital treatment for the assessment of sleep patterns and anomalies such as snoring and sleep apnoea.

In-hospital treatment for tonsils, adenoids and insertion and removal of grommets.

In-hospital treatment for weight loss surgery such as gastric banding and bypass and sleeve gastrectomy.


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