Private health insurance reforms: Clinical categories

To make private health insurance easier to understand for consumers, a new list of clinical categories for hospital treatment will be introduced from 2019.

Page last updated: 11 January 2019

Private health insurance reforms: Clinical categories (PDF 222 KB)

  • Private health insurers will be required to use standard clinical categories across all of their documentation and across all platforms. These clinical categories will be introduced from 1 April 2019 and insurers have until 1 April 2020 to adopt the clinical categories for all products.
  • The Clinical Definitions Working Group, established by the Private Health Ministerial Advisory Committee, has developed a list of standard clinical categories which is consumer-friendly, easy to understand and designed to cover all services.
  • Consumer testing has been done to ensure that the list of clinical categories is appropriate for use by consumers.
  • A table describing the clinical categories is available at Private Health Insurance Reform Rules 2018 under the heading Supporting Material. Details about the clinical categories arrangements are set out in the <em>Private Health Insurance (Reforms) Amendment Rules 2018</em>, which can be accessed at and search by title.

Why is this important?

  • The Government’s private health insurance consultations revealed that a key concern for consumers was complexity and ease of understanding of private health insurance products.
  • Introducing a standardised set of clinical categories which define inclusions and exclusions will help consumers make an informed choice about private health insurance and what different products do, and do not, cover.

Who will benefit?

  • The clinical categories will assist consumers to understand their own products and allow them to compare and understand different health insurance policies.

What impact will this change have on private health insurance?

This change is designed to help consumers compare different products more easily and understand what they are, and are not, covered for.