Claim for common treatments and items such as dentistry and glasses with extras health insurance.
Extras cover (or just extras) is a form of private health insurance that allows you to claim benefits for non-hospital related medical services that are not covered by Medicare. This article aims to give you a general breakdown of the different tiers of policy available, the services which are typically covered and other useful information so that you are able to compare this type of health insurance with confidence and make the right extras cover decision for you.
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What levels of health insurance extras are available?
Although the names of each tier of extras health insurance will vary between funds, they will typically offer benefits for a comprehensive, medium or basic range of treatments and services.
- Comprehensive extras. The highest level policy available and also the most expensive, it is designed to suit the needs of mature singles, couples, families and others with extensive health care needs. It covers the broadest range of non-hospital treatments and pays the highest benefits on claims. Common services covered include major dental, orthodontics, endodontics, home nursing, alternative therapies, remedial massage, weight loss programs and more.
- Medium extras. If you are middle-aged or have a growing family, this intermediate policy can be a good choice for balancing affordability and cover. It pays benefits for a broad range of services, has reasonable premiums and is typically suited to those with an average need for health care services. Services that you can expect to be covered for include major dental, optical, physiotherapy, occupational therapy and more.
- Basic extras. Designed for those who are young, fit and healthy and not in need of a high level of cover, this policy will pay benefits for a limited selection of vital treatments such as general dental, optical and physiotherapy. While annual benefit limits will be smaller compared to medium or comprehensive extras policies, the cost of premiums for basic extras is also lower.
What services can I typically claim for?
Below you can find examples of commonly claimed for medical services that comprehensive, mid and basic extras will pay benefits for. This is by no means an exhaustive list, and you will find most extras will include a wide range of services.
Covers the widest range of services with the highest benefit limits
- All treatments covered by basic and mid extras. With a higher level of annual benefit limits applied to your cover than basic and mid extras.
- Orthodontics. Covers crowns, bridges, dentures, implants, removal of wisdom teeth and other services performed by orthodontists.
- Non-pbs medications. Covers certain pharmaceutical items that are not eligible for benefits under the Pharmaceutical Benefits Scheme.
- Psychology. Often only available after the Medicare benefit has been used up. Covers individual or group sessions.
- Dietetics. Pays towards the cost of consulting with a dietician or nutritionist to develop healthy eating plans and achieve weight loss goals.
- Audiology. Hearing aids and speech processors are often covered under this benefit to help improve hearing.
Slightly less cover and benefits but more affordable than top extras
- All treatments covered by basic extras. With a more generous amount of annual benefit limits applied to your cover than basic extras.
- Major dental. Includes tooth extractions, complex fillings, root canal therapy and dental implants.
- Podiatry. Covers treatment of conditions related to the feet and lower limbs such as arthritis, ingrown toenails and callouses.
- Travel vaccines and immunisations. Some policies will cover vaccinations you may require before heading overseas such as inoculation against yellow fever.
- Occupational therapy. Treatments to help with recovery from the effects of injury, illness, psychological trauma and in some cases ageing.
- Exercise physiology. If exercise is deemed necessary to help with rehabilitation, medium extras policies may pay a basic benefit.
Basic option for those who only need cover for essential extras services
- General dental. Includes removal of plaque, application of fluoride, filling procedures, X-rays and basic extractions.
- Optical. Covers some, or all, of the cost of glasses frames, lenses and contact lenses up to a certain limit.
- Physiotherapy. Typically includes cover for an initial appointment with a physiotherapist as well as subsequent appointments.
- Chiropractic. Covers therapies that involve manipulation to treat nerve-related skeletal and muscular conditions.
- Osteopathic. Covers treatments that involve manipulation to improve balance and mobility, including back and neck pain.
- Emergency ambulance. Covers the cost of medically necessary ambulance transport to hospital.
Extras, taxes and premium loadings
The Australian Government has introduced three incentives and penalties to encourage people to take out private health insurance. These are the private health insurance rebate, the Medicare Levy Surcharge (MLS) and the Lifetime Health Cover loading (LHC). So does holding an extras policy without hospital cover allow you to take advantage of, or avoid these schemes?
- Private health insurance rebate. Extras only policyholders are eligible.
- Medicare Levy Surcharge. Requires hospital cover to be exempt.
- Lifetime Health Cover loading. Requires hospital cover to be exempt.
So in order to avoid the MLS and the LHC you will need to take out a combined hospital and extras policy, but holding extras only still allows you to take advantage of the private health insurance rebate, which can be paid either as a premium reduction or as a tax deduction. The exact rebate you will be eligible for is affected by your income level and your level of cover.
Will I have to serve waiting periods on claims?
Like hospital cover, waiting periods for benefits apply to extras too. As a general rule you will need to serve a two month waiting period for your claim to be paid on treatments such as general dental, optical, physiotherapy and natural therapies. However, longer waiting periods may apply to more specialised services, some examples of which can be found below.
- Major dental. Expect to serve a 12 month waiting period.
- Hearing aids. The waiting period for hearing aids can range from 12 to 36 months.
- Health management programs. A six month waiting period commonly applies.
One important point to keep in mind about extras health insurance is that, unlike with hospital cover, each health fund is free to set waiting periods of its choice. Therefore, keep an eye out for promotions which may waive waiting periods to attract new members, but also be more vigilant about checking the fine print before purchasing an extras policy.
How can I avoid or reduce out-of-pocket expenses?
Unless you are treated by a doctor that bulk bills, you may still have to pay out-of-pocket expenses for extras services if the medical practitioner charges above the Medicare Benefits Schedule (MBS) fee. Luckily, several policy and health fund features exist that can help prevent unpleasant surprises when the bill arrives.
- Full gap cover. If you are willing to spend more on your extras policy opt for one that offers full gap cover. This will negate 100% of any additional costs you may incur.
- Known gap cover. If cost is a concern, find an extras policy that includes known gap cover. While out-of-pocket expenses will not be completely negated you will know what the amount will be before being treated and can budget accordingly.
- Preferred providers. Many health funds have a network of affiliated health care providers. Getting treatment or purchasing items such as glasses frames from these providers can further help to reduce your out-of-pocket expenses.
Answers to common extras questions
Why are waiting periods applied to extras?
What are annual benefit limits?
What is the difference between set and percentage benefits?
How do I lodge extras claims?
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