Comparing Orthodontic Health Cover

By Dr Daniel De Angelis

treatment coordinator orthodontic consultation

Choosing which health insurance fund is right for you, and your family, when it comes to orthodontics can be overwhelming.

If you are considering orthodontic treatment and aren’t sure which health insurance is right for you, there are a couple of things to consider when comparing orthodontic health cover.

Many health insurers will contribute to orthodontic treatment including braces, aligners and retainers as part of ‘Extras’ cover. Extras cover, or general treatment, is a component of health insurance that covers services that usually Medicare does not.

Firstly, all covers will include a 12 month waiting period and this will apply to you if you are new to private health insurance or upgrading your cover and considering transforming your smile. If you do have health insurance and are transferring to another fund, in most cases your waiting periods will travel with you so this decision won’t delay your treatment start.

As every patient is unique, I will prescribe treatment tailored to your individual needs. The cost of treatment is therefore dependant on the type and duration of treatment and will vary from patient to patient. After an initial examination you will receive a detailed treatment plan, including the total cost and expected timeframe.

I encourage you to ask as many questions from your health fund prior to your first visit because, with the right knowledge, you can start your orthodontic journey on the same day!

Alternatively, whilst our staff cannot directly liaise with your private health insurer on your behalf, our team will provide you with all the information you require at your initial consultation to discuss any rebate you may be entitled to. We encourage all our clients to discuss this with us prior to treatment commencing.

Please note that the information in this blog is factual information only and is not intended to imply any recommendation or opinion about the types of cover available and whether they are suitable for you.

What types of private health insurance are available to cover orthodontic treatment?

There are several types of dental services offered with most private health insurance companies ‘Extras’ policies;

  • General Dental – this includes hygiene such as cleaning and scaling, x-rays, fillings, extractions, etc.
  • Major Dental – this includes more complex dentistry procedures such as wisdom teeth extraction, crowns, implants and bridges
  • Orthodontic treatment is a specialised treatment that corrects malpositioned teeth and jaws and is often listed separately within the Extras so this is the cover you’ll need to consider.

It’s important to realise that even though some Dentists offer orthodontic treatment, it may not be covered within the Major Dental component of your health insurance because it has not been prescribed by a Specialist Orthodontist. Some health funds may pay a lower benefit if you see a Dentist for your orthodontic treatment.

The Major Dental component of your private Extras cover usually covers a proportion of your orthodontic treatment including braces and in most cases aligner treatment although, it is a good idea to confirm with individual funds if this is the case.

Many ‘basic’ Extras covers do not include Major Dental and generally you need to look at a mid to comprehensive level of Extras cover.

Are all ‘extras’ covers the same?

Whilst Extras cover varies between the health funds, each fund may offer several choices with varying levels of benefits within the Extras policies.

For example, some funds will offer a base rate of cover with a lower contribution for a lower level of benefit, through to a “Platinum” cover with a much higher contribution and equally high benefit in return. The choice is yours based on your budget.

“Premium”, the amount you contribute each month, also depends on several contributing factors including who is covered under the policy (i.e. families, single parents, couples etc) and the type of cover purchased.

Like many other insurance products, each policy will come with different features, limits and benefits, so be sure you are comparing apples with apples.

How do limits and waiting periods apply?

All health insurance extras covers will typically include a 12 month waiting period. This will apply to you if you are new to private health insurance and considering transforming your smile.

If you do have health insurance and are transferring to another fund, in most cases your waiting periods will travel with you so this decision won’t delay your treatment start. This is great news!

However, some health funds offer incentives the longer you remain with them by way of accrued benefits that increase over time. Under this arrangement, your annual benefit will continue to increase until you reach the maximum benefit.

These ‘loyalty limits’ are important to consider prior to changing health funds as often these benefits are not transferable.

Some health funds will not pay benefits towards orthodontic treatment (including payment plans) if treatment has commenced prior to joining their fund so it’s important to research carefully prior to commencing your treatment.

What does the ‘Benefit Limit’ mean?

Just like the differences in general and major dental, there are differences within the benefits claimable.

All extras have a limit on how much you can claim each year (12 month period) for a particular treatment and some have lifetime limits, the maximum amount over your lifetime you can claim.

Sub-limit

A sub-limit is the largest possible amount you can claim for a specific service, which is then deducted from a larger overall benefit. For example, you might have a large overall benefit, however there are smaller limits for individual and specific services within this benefit.

Shared or combined benefit limit

This means the benefit limit is shared across multiple services and, while you are not restricted to claiming a capped amount for one service, your total overall benefit is shared amongst treatments.

Lifetime benefit limit

This is the maximum amount you can claim for a service throughout your lifetime. In most cases, orthodontic treatment carries lifetime limits.

Importantly, if you have used your lifetime limit with one health fund and you transfer to another fund, your lifetime benefit may travel with you and the amount may be deducted from your new fund.

How do I claim for orthodontic treatment?

To assist with the cost of treatment we can arrange 0% interest free payment plan solutions to suit your budget and offer discounts for those who opt to pay in full at the commencement of treatment. Both options are suitable to start claiming benefits through your health fund and we’ll make claiming for your eligible rebate as smooth as possible.

To assist in claiming from your health fund, we have HICPAS terminals available at all of our clinics where you will be able to claim at the time of your consultation.

Alternatively, we will provide you with a tax invoice or receipt in order for you to obtain your eligible benefits from your health fund.

It is important to remember, although you may have made a payment by way of a deposit, some benefits with some health funds are not payable until treatment has commenced. This may be the case if you have been prescribed clear aligner treatment. In this case, you will be eligible for your benefits once you have received your first set of aligners.

A few other things!

Lifetime Health Cover Loading (LHC)

LHC is a government incentive to encourage Australian’s to take out private hospital insurance at an earlier age to avoid a loading being applied to your cover – in other words, the longer you wait after your 31st birthday, the greater the loading payable.

The good news is the LHC does not apply to Extras cover, so you can take this cover out any time without penalty.

Australian Government Rebate

The Australian Government Private Health Insurance rebate is designed to help you pay for your premiums and, much like the LHC, to reduce the burden on our public health system. Depending on your taxable income, personal circumstances and Medicare eligibility, you may qualify for a rebate on Extras cover.

We hope this will help you to navigate some of the complexities in understanding private health insurance and have prepared a summary of health funds who offer orthodontic benefits.

We encourage you to check with your health fund quoting the item numbers 881 for braces treatment and 825 for aligner treatment. Our team is here to help you with this.

Of course it’s important to consider all your health insurance needs that suit you and your family, in deciding on a fund that is appropriate for you.

We have provided a snapshot of some of the most frequently considered health funds below.

The figures below are indicative of the maximum benefit payable and do not take into consideration the type of treatment and associated item number.

TOC is not aligned with, nor endorses, any Health Fund.

FundExtrasAnnual LimitLifetime Limit
AAMI
Premium Active

Everyday Active
$700 increasing by $100 per year to lifetime limit

$500 increasing by $100 per year to lifetime limit
$2,500

$1,700
AHMSuper
Family
Lifestyle
$900
$700
$600
$2,900
$2,200
$1,800
Australian UnityAdvanced 80%
Classic
$800
$600
$2,400
$2,400
BupaPlatinum
Gold
Silver
Your Choice
$900
$800
$700
$450 increasing to $900 after 7 years (loyalty rewards)
$2,800
$2,600
$2,000
$1,300
CDHGold
Silver
$600
$400
$2,500
$1,800
CUATotal
Classic
$900
$500
$2,500
$1,500
GMHBAGold


Silver
$450 increasing after 3 yrs and capped at $850 after 10 yrs
$320 increasing after 3 yrs and capped at $570 after 10 yrs
$2,900

$1,900
HBFTop 70
Complete 60
$800
$600
$2,400
$1,800
HCFVital
Platinum
Gold
$700
$400
$350
$2,100
$1,200
$1,050
HIFPremium Options


Super Options


Special Options
$1,500 in the first year increasing to $3,000 after 5 yrs to lifetime limit
$1,300 in the first year increasing to $2,500 after 5 yrs to lifetime limit
$1,000 in the first year increasing to $2,000 after 5 yrs to lifetime limit
$1,500 in the first year increasing to $3,000 after 5 years
$1,300 in the first year increasing to $2,500 after 5 yrs
$1,000 in the first year increasing to $2,000 after 5 yrs
Healthcare InsPremier
Healthy
$900
$600
$2,700
$1,800
health.com.auActive 60
Extras 50
$600
$500
$1,800
$1,000
Health PartnersBest


Better
$900 in the first year increasing to $2800 after 4 yrs to lifetime limit
$800 in the first year increasing to $1500 after 4 yrs to lifetime limit
$2,800




$1,500
MedibankTop

Growing Family
$400 opening balance topped up $200 per year
$100 opening balance topped up $100 per year
$1,200

$1,200
Mildura Health FundFive Star$720 (sub-limit)$2,000
NIBTop
Core Family
$800
$350
$2,600
$1,500
OneMediFundExtras Plus$2,100 increasing to
$2,600 after 5 yrs
Qantas InsuranceTop
Family
$800
$600
$2,600
$1,500
St Lukes HealthSuper$1,000 (sub-limit)$2,800

 

** Restricted funds: There are health funds such as Defence Health and Navy Health, etc. that only provide cover to members of specific industries, groups and organisations. In some cases family members may also be eligible to join. Therefore these have not been included within the table.

Please note: information was correct at the time of writing on 1 July 2020. For further information please visit https://www.privatehealth.gov.au/dynamic/search