Private Health Insurance and Orthodontics - What Is Covered?

Treatments & Care

Mum paying for childs orthodontic treatment and checking her private health insurance cover.

Orthodontic treatment is an investment that pays returns for a lifetime. Whether orthodontics are for medical or cosmetic purposes, most private health insurance funds in Australia offer policies that cover part of the cost. 

It’s possible to find out how much your health insurance fund covers for orthodontics before you start treatment so there are no surprises.  

Hospital and Extras Health Insurance Cover

A combined hospital and extras health insurance policy covers you for hospital treatment and general (extras) treatments (non-hospital) such as dental, physio, chiro, remedial massage and much more. 

Hospital Cover

Hospital cover is for treatment and accommodation costs while in hospital. If you suffer an injury or illness and want treatment as a private patient, you will need hospital cover. You are also less likely to need to wait for non-life threatening surgery as a private patient. 

Hospital cover provides the following benefits:

  • Being treated as a private patient in a private or public hospital

  • Able to choose your own doctor

  • Little or no waiting periods 

  • Avoids the Medicare Levy Surcharge if your income is over a certain level

  • Avoids the Lifetime Health Cover loading of 2% for every year you don’t have hospital cover over the age of 31 years

Health funds have bronze, silver and gold levels of hospital cover. 

Extras Cover 

An extras policy can reimburse you for general services that aren’t covered by Medicare. These include dental, optical care, physiotherapy, osteopathy, acupuncture, hearing aids, podiatry. 

Most funds have three levels of extras cover – basic, medium and comprehensive. Basic cover is suitable for people who only need general dental services while comprehensive cover is required for major dental treatment. 

General Dental

General dental covers basic dental treatment such as a check-up, clean and scale, a tooth extraction, and x-rays. However, you might not be fully covered and there could be a gap you need to pay.  

Major Dental

More extensive treatments such as crowns, bridges and root canals require major dental cover. Removal of wisdom teeth, jaw surgery and orthodontic treatment also require a policy with major dental. 

Some health funds increase the benefit based on the number of years you’ve been a member of the fund. For example, if you have been with a fund for 12 months, you may receive a benefit of $500 towards the cost of your orthodontics. For every extra year you’ve been a member (to a maximum of five years), the benefit may increase by $200. Accrued orthodontic benefits may not transfer to another fund if you change funds. Other funds have a fixed benefit with a maximum cap. 

Most health funds have a ‘Lifetime Limit’ for orthodontic treatment. Once you have claimed your maximum benefit, you can’t make another claim for orthodontics. Check with your health fund to find out the maximum benefit you can claim.  

Variations in Health Insurance Payments for Orthodontics

Patients receive different amounts back on orthodontic treatment for a variety of reasons. 

Health Fund

The health fund will determine how much you are eligible to get back on orthodontic cover. Some funds are more generous than others on dental and orthodontic rebates. You can find more information on annual limits and premiums on comparison sites or by contacting individual health funds. 

Level of Extras Cover

Most health funds have different levels of extras cover. Generally, the higher the premium, the more services you claim on and the more you get back when it comes time to make a claim.   

Time with Fund 

Some private health funds reward members who have been with them for multiple years. These members may receive a higher rebate that covers more of the orthodontics cost. Funds often pay members who have been with the fund for 12 months the minimum rebate while those members who have been with them for five or more years, receive the maximum rebate. 

Lifetime Cover

Many Australian health insurance funds have a lifetime limit on orthodontics. So once you have received the maximum rebate, you can’t make another claim with any health insurer for orthodontics. 

Age of Patient

Some health funds treat children and adults differently in terms of the rebate they receive on orthodontic treatment. 

Waiting Period

Most health funds have a waiting period of 12 months for orthodontic treatment. If you have taken out a health insurance policy to help pay for orthodontics, you may start the preliminary treatment before the 12 months is up. Most funds pay the rebate on the day the orthodontist fits the braces. If you are keen to get your orthodontic treatment underway, check with your fund on what date you are eligible to ensure you meet the waiting period requirement.  

How Can I Find Out How Much I Will Get Back on Health Insurance?

There are various ways you can find out the maximum dollar value your health insurer will cover for orthodontic treatment. 

Your Treatment Plan

When your treatment plan is provided to you, it includes item numbers for each of the different treatment types and options you may choose from. You can use the item numbers to find out rebate details. Your health fund may request a copy of the written treatment plan to give you a benefit quote for orthodontics. Your treatment plan includes details of:

  • Type of treatment

  • Estimated length of treatment

  • The total cost of treatment

  • How you intend paying i.e. an upfront payment or instalments 

At the Clinic

If you bring in your health insurance card, the clinic reception staff can swipe your card and enter the item numbers to determine your rebate. This service is available for patients of all funds except HBF. Patients with a HBF policy should contact the fund directly for a benefit quote.  

Contact Your Health Insurer

Use the item numbers the clinic provides to contact your health fund. Call or email the fund to find out how much you’re eligible to receive back. 

If I Don’t Have Extras Health Insurance, Should I Take It Out?

You need to do your research. Some health funds will only cover a few hundred dollars towards orthodontics while a few funds cover up to $3,000. You need to consider how much you will pay out in premiums compared to the value of the rebate. According to Choice research, you will be out of pocket if you pay health insurance premiums for three years and only claim one course of orthodontics.    

If you have more than one person on the policy needing orthodontics and you plan to do the orthodontic treatments simultaneously. You can save on the number of years of premiums, but there may be annual policy limits to take into account. It’s worth crunching the numbers to see if it will be worthwhile taking out a health insurance extras policy or paying the full amount for orthodontics.

Will the Government Help Cover the Cost of Orthodontics?  

Some people can save a small amount of the cost of orthodontics through the government.  

Child Dental Benefits Scheme  

The Child Dental Benefits Scheme covers dental expenses for children aged 2-17 years if their parent receives an eligible Centrelink payment. Orthodontic treatment isn’t covered by the scheme however you may claim for x-rays or extractions.  

Can I Claim on Medicare?

Medicare will only cover the cost of braces under the Cleft Lip and Cleft Palate Scheme

Can I Claim Orthodontic Treatment on My Tax Return? 

No. In the past, the ATO considered some non-cosmetic orthodontic treatment a medical expense. However, the ATO phased out the Net Medical Expenses Tax Offset around five years ago.   

Considering Orthodontic Treatment as an Adult?

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Flexible Payment Plans

We understand that paying the full cost of orthodontic treatment upfront is a financial burden for many families. The Orthodontists provide payment plans so we spread out the cost of treatment (after the initial upfront payment). The payment plan scheme is available to all patients whether or not you have a health insurance policy. 

More Information

If you have any queries about health insurance rebates or payments, don’t hesitate to contact the receptionist at your clinic. We’re happy to answer any queries you may have.  

Category: Treatments & Care