optometry treatment

Health insurance and eye care

How to get optometry and eye care covered by your health fund

Eyes are complicated, so a lot of things can go wrong with them. That’s why it helps to have optical private health insurance to cover optometrist visits and other eye care. Lifetime eye care includes regular check ups and, depending on your needs, might also include glasses or contact lenses, vision therapy, laser eye procedures or cataract and other eye surgery.

What optometry costs will your health fund cover?

While cover will vary depending on your policy, you can receive cover for:

  • Check ups and examinations
  • Glasses and contact lenses
  • Eye disease
  • Eye surgery for medical issues
  • Vision therapy
  • Laser eye surgery
Medicare provides cover for some of these benefits, but for full cover you’ll need private health insurance.

Optometry serviceDoes Medicare cover it?Can private health insurance cover it?
Check ups and examinationsYesYes
Eye surgery for medical issuesYesYes
Eye diseaseYesYes
Glasses and contact lensesNoYes
Vision therapyNoYes, as an extra
Laser eye surgeryNoYes, as an extra

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How do I know if something is covered by Medicare?

If something is medically necessary, such as regular eye examinations or treatment for a disease, then it is most likely covered by Medicare. If something is not medically necessary, such as cosmetic or laser eye surgery, or if it involves providing equipment or aids, such as contact lenses or glasses, then it’s not covered by Medicare but generally can be covered by your private health insurance.


Should you get optical cover with private health insurance?

When deciding whether you are at risk of optical issues and whether you should get health insurance to cover them you should consider age as a factor. Eye disease and serious issues are relatively uncommon in younger age groups, but very common in older demographics.

  • 31% of older Australians (over the age of 55) have cataract presence, compared to less than 5% under that age.
  • More than 40% of older Australians are visually impaired, in contrast to less than 5% of younger Australians.
  • Almost 20% of Australians aged 90+ are blind, but less than 1% of younger Australians are.

What should I look for in a health insurance policy?

There are some terms and conditions you should look out for when finding an insurance policy.

Exclusions

Exclusions are the things that aren’t covered by your private health fund. Some frequently encountered exclusions are:

  • Treatment outside of Australia. If you want to head abroad for cheaper laser eye surgery, for example, most health funds won’t cover that. You might consider medical tourism insurance instead.
  • No cover unless there is a specific, named health issue involved.
  • No cover for additional costs like administration fees.

Limits

These are the maximum amounts your policy will pay in benefits, or how much you can claim before your benefits cap out. Your policy may have yearly or lifetime limits for a number of treatment sessions or an amount of money paid out.

  • If the cost of a treatment is more than the limit of your policy, you will only be covered up to that limit and must pay the rest yourself.
  • In the case of family or couple policies there may be limits for individuals as well as limits for the group as a whole.

Excess

This is an additional amount you must pay when making a claim and you may encounter one or more of these. If more than one excess applies, you must pay the total sum of all applicable excesses.

  • Age related excess. The older you are the higher your risk levels. Certain age groups have this additional excess.
  • Hospital excess. If someone on your policy goes to hospital this excess will apply to cover the additional costs involved.
  • Special excess. Pre-existing conditions, ongoing health issues or a history of making many claims will drive up your special excess.

How do I make an optical cover health insurance claim?

Depending on the procedure and your fund, there are a few ways to make a claim. Some claims may require more than one of these. For example, you might be able to claim a procedure online, but you may be required to fill out a claims form and mail it in to claim the related ambulance ride.

  • Use an app. Some health funds offer a mobile app you can use to make a claim. This is an easy way to do it but might not always be an option.
  • Claim online. Visit your fund’s website to make a claim online. Login with your details and go to the claims section. From there you can follow the steps, provide the information required and have the benefit paid sent directly to your bank account or mailed as a cheque.
  • Send in a claims form. Download a claims form from your fund’s website, fill it in and mail it off to the address provided. Your claim will be processed and handled accordingly.

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Picture: Shutterstock

Andrew Munro

Andrew writes for finder.com.au, comparing products, writing guides, sniffing out deals and looking for new ways to help people get the most out of their money.

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