Dental extras with private health insurance [PHI]

Should I take out dental extras with my private health insurance [PHI] for orthodontic treatment?

There is no dental equivalent to ‘Medicare’ when it comes to dental care. Medicare does not cover orthodontic treatment.
For those people that have PHI but no dental extras and are considering orthodontic treatment then the cost of taking out optional insurance for dental extras to cover some of the cost of orthodontic treatment can enter into their thinking. The decision whether to take out PHI + dental extras can also enter into the minds of those with no PHI insurance. Here are some questions and answers you might find helpful. Links to some ADA [Australian Dental Association] publications addressing PHI which could also be of interest are listed at the end of the article.

How long do I have to be a member of a fund before I will be eligible to claim rebates associated with orthodontic treatment?

Most funds will have a requirement that to access rebates for orthodontic treatment you are a member for a certain ‘waiting or qualifying’ period before you are entitled to claim rebates towards treatment costs. There may also be conditions attaching to such rebates as ‘excluding pre-existing conditions’ which might affect your ability to claim for treatment where this has already commenced.

How much will my fund rebate for orthodontic treatment?

Just as there is no set ‘fee’ for orthodontic treatment, there is no set ‘rebate’ for orthodontic treatment. You might want to ask your health fund what is the maximum amount they will rebate for a full course of orthodontic treatment [complete or comprehensive orthodontic treatment] and what conditions are attached to this rebate [how do I qualify?]. Some health funds might tier the amount they rebate for orthodontic treatment depending on how long you have been a member. The same fund might also have different membership packages which attract different rebates. Members of long standing may attract a higher rebate compared to members of lesser duration. Rebates can also be different within the same fund depending on the professional registration of the person delivering the orthodontic treatment. Some funds will provide a higher rebate amount if that treatment is being delivered by an Orthodontist [Specialist in Orthodontics] as opposed to a Dentist [General Dentist or “Generalist”]

Over what time frame will my health fund provide rebates?

This can vary depending on your health fund and their policies. Check with you health fund over how many years or months will they provide a rebate towards orthodontic treatment. Is there a limitation? Check whether the rebate is calculated on the basis of a calendar year [January – December] or a financial year [July – June] as this could affect your claim.
Let’s look at an example of treatment commencing in say April 2000 and finishing in November 2001. In this example treatment has extended over 19 months which happens to be over 2 calendar years [2000 and 2001]. If payments towards the cost of the orthodontic treatment commence when treatment starts in April 2000 and conclude in say October 2001 payments have been made over 3 financial years [2000, 2001 and 2002].
Check with your health fund if you pay upfront for orthodontic treatment [in a ‘lump sum’] will this have any affect on the amount of rebate you are entitled to claim. Is the rebate amount dependent on the time treatment takes? Are there any other conditions attaching to this rebate amount?

How many claims can I make for orthodontic treatment?

Check with your health fund on their policy in relation to ‘lifetime’ limits in relation to orthodontic treatment. Is it up to a ‘dollar’ limit, a certain maximum amount regardless of how many orthodontic treatments? Is it limited to only ‘one’ claim for orthodontic treatment for the life of a person? Is it limited to a certain amount each year [calendar/financial] which resets so long as membership is retained?

Can the Child Dental Benefits Scheme [CDBS] be used towards the costs of orthodontic treatment?

In its present format the CDBS cannot be used towards the cost of orthodontic treatment. Further information regarding this scheme can be accessed via the following link: health.gov.au/internet/main/publishing.nsf/Content/childdental
At the end of the day the decision will come down to the ‘value’ proposition for the circumstances of your particular situation. Are you better off paying for treatment without the additional PHI extras policy burden or without taking out PHI insurance + dental extras? Does the rebate you are entitled to cover the cost of upping the policy coverage not only for the qualifying period but for the orthodontic treatment duration or indeed taking out PHI + dental extra’s for same?
For those without PHI I suspect the case for taking out PHI + dental extras might not stack up when the numbers are crunched. This is especially so when the insurance is being used purely to assist with orthodontic treatment costs. For those with PHI and considering adding ‘dental extras’ the situation could be more favourable; especially if this is within the setting of a family policy. Remember ‘dental extras’ covers more than just orthodontic treatment. As with any insurance ‘the devil is in the detail’. Don’t rush the decision, get as much information as possible and then make an informed decision based on your circumstances.
In terms of forward planning, you might want to also consider an ‘early’ visit to an orthodontist, before you intend undertaking treatment or before you think your child will need treatment. In this context ‘early’ for children is around the ages of 8-9 years when they have their upper and lower 4 adult front teeth. The orthodontist should be able to give you feedback as to the likely need or otherwise for orthodontic treatment in the teenage years. Some children at this age might also need treatment at this time.
The ADA [www.ada.org.au] has articles related to PHI under the banner “Private Health Insurance Get the Facts”. Clicking on this banner will reveal these articles. Links to some of these articles can be found below.

adaftp.com.au/PHI/PHIFactSheet.pdf
ada.org.au/app_cmslib/media/lib/1305/m610866_v1_private%20health%20insurance%20
essential%20questions%20fact%20sheet.pdf

ada.org.au/app_cmslib/media/umlib/062015preferredproviders_2sidedbrochure_.pdf
phio.org.au

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