Is it possible to get no-gap optical?
Even if optical is included in your private health insurance extras cover, if your optometrist charges more for their frames and lenses than your benefit limit allows, you will have to pay the medical gap yourself. Many health funds address this problem by offering no-gap optical schemes and this guide looks at what these cover and which health funds are providing them to their members.
Optical services and health insurance
Other than eye exams and checkups with an optometrist, which can often be bulk-billed, optical services are not covered by Medicare. Prescription lenses, frames and contact lenses are not covered. If you don’t have private health insurance extras cover, you will have to pay for these out of your own pocket.
Extras cover is available in several levels (basic, medium and comprehensive) and generally covers ancillary services such as optical, dental and physio up to set annual benefit limits.
What is the medical gap and how do I avoid it?
If a doctor charges a higher fee than the Medicare Benefit Schedule (MBS) fee for a service, the medical gap is the difference between the MBS fee and the doctor’s fee. This amount will have to be paid either by your health fund or by you.
In the case of optical services that are not listed on the MBS, the medical gap is the gap between what an optometrist charges for lenses and frames and what your private health extras cover will pay towards them.
To avoid having to pay any medical gap, you need to be with a health fund that has a no-gap scheme. A no-gap optical scheme is one where a health fund agrees to cover the medical gap if members go to a preferred optometrist or an optical dispenser with which the health fund has an arrangement. These practices charge capped prices that have been agreed upon with the health fund for a select range of lenses and frames.
Which health funds have a no-gap optical scheme?
|Fund||What’s covered?||More info
|HCF offers a range of fully covered services through their More for You provider network, including 100% back on a range of prescription glasses and one free digital retinal image per calendar year.||More info|
|HIF’s No Gap scheme only applies to contact lenses, but they also offer a range of discounts for members who shop for glasses and contacts both instore and online.||More info|
|nib Eye Care offers members 100% back on three ranges of complete single vision prescription glasses and selected contact lenses (depending on your level of cover) with free delivery anywhere in Australia.||More info|
|Transport Health offers members a choice of single vision, bifocal and multifocal glasses from several ranges at Specsavers (depending on your level of cover).||More info|
|CBHS offers its members 100% back on the cost of frames, lenses and contact lenses from a selected range at any of its Choice Network Providers, up to the maximum per service and overall limits.||More info|