If you have private health insurance with extras cover, it can make dental care much more affordable. But extras policies can be confusing: annual limits, waiting periods, item numbers and gap payments all affect what you pay. This guide explains the basics so you can get the most out of your cover.
Hospital cover vs extras cover
Hospital cover helps with treatment as a private patient in hospital. Most everyday dental care, such as check-ups, fillings, crowns and orthodontics, falls under extras cover (sometimes called general treatment or ancillary cover). Medicare generally doesn’t cover dental care for adults, with some exceptions such as certain public dental programs. For eligible children, the Child Dental Benefits Schedule may help.
How dental extras are usually grouped
Funds typically group dental services into categories, each with its own rules:
- General or preventive dental: check-ups, scale and clean, fluoride, x-rays. Often has short or no waiting periods.
- Major dental: crowns, bridges, dentures, root canal treatment, some extractions. Often has a waiting period of around 12 months.
- Orthodontics: braces and aligners. Often has a long waiting period and a separate lifetime limit.
The exact rules vary by fund and policy, so check yours.
Key terms
Annual limit
The maximum your fund will pay towards a category in a year. Some funds reset limits on 1 January, others on 1 July or on your policy anniversary.
Waiting period
How long you must hold cover before you can claim for a service. Waiting periods usually restart if you upgrade your cover.
Item numbers
Dental services are described with standard item numbers from the Australian Dental Association’s schedule. Your fund uses these to work out your benefit. If you want an estimate, ask your dentist for the item numbers on your treatment plan and call your fund.
Gap
The difference between the fee and what your fund pays. Some services may be no gap, meaning the fund’s benefit covers the full fee.
What “no gap” means
At some practices, certain preventive services are no gap for members of eligible funds. At Parramatta Dentistry, a new patient visit, which includes a comprehensive examination, consultation, scale and clean, and x-rays (bitewings and OPG), is no gap with an eligible health fund, or $219 without health fund cover. Returning patients can have a check-up and clean for $199 without x-rays, $259 with bitewings or an OPG, or $309 with both. Conditions apply, and fees may vary with your clinical needs. Whether a service is no gap depends on your fund, your level of cover and how much of your limit you’ve already used.
Claiming on the spot with HICAPS
HICAPS is a terminal that lets you claim your benefit at the end of your appointment. You swipe or tap your health fund card, the benefit is processed straight away, and you pay only the gap, if there is one. There’s no need to lodge a claim later. Parramatta Dentistry has HICAPS on site, and we work with members of Bupa, Medibank, nib, HCF and most other health funds.
Making the most of your extras
- Book your preventive visits. Many policies include two check-ups and cleans a year. Regular visits can help avoid bigger costs later.
- Check when your limits reset. If your limits reset on 1 January, using remaining benefits before then can help, but only book treatment you need.
- Ask for a written treatment plan with item numbers so you can get a quote from your fund.
- Plan larger treatment across two years where it’s clinically reasonable, so you can use two years of limits. Your dentist will tell you if delaying treatment carries risks.
- Check your waiting periods before booking major treatment.
Questions to ask your fund
- What is my annual limit for general dental, major dental and orthodontics?
- When do my limits reset?
- Have I served the waiting period for this treatment?
- How much will you pay for these item numbers?
No health insurance?
If you don’t have extras cover, ask about our fees and payment plans for larger treatment. Some treatments are available on weekly payment plans, which can help spread the cost. Conditions apply.
Read more on our health funds and HICAPS page.
Frequently asked questions
Why is my gap different from my friend’s?
Benefits depend on your fund, your level of cover, the item numbers on your treatment and how much of your annual limit you’ve used. Two people at the same practice can pay different gaps for the same treatment.
Can I claim for my partner and children?
On family policies, limits may be per person or shared across the family. Check your policy details, as this affects how much you can claim.
Does Medicare cover the dentist?
Medicare generally doesn’t cover dental care for adults. Eligible children may receive benefits through the Child Dental Benefits Schedule, and some people may be eligible for public dental services.
What is a preferred provider?
Some funds have arrangements with particular practices, which can affect the benefit you receive. Ask your fund how their arrangements work and how they affect your out-of-pocket costs.
Do I need my card with me?
Yes. Bring your physical health fund card or your digital card if your fund supports it, so we can process your claim through HICAPS at the end of your appointment.
Book at Parramatta Dentistry
Parramatta Dentistry is at Suite 25, Level 3, 27 Hunter Street, Parramatta, a short walk from Parramatta Station. We’re open Monday to Friday, 9am to 6pm, and HICAPS is on site, so you can claim from your health fund on the day and pay only the gap, if there is one. Call (02) 8090 1109 or book online.
This article is general information only and isn’t a substitute for personalised advice from your dentist.