Extras cover in private health insurance

Depending on your level of extras cover, you can be covered for a range of services from accredited or recognised healthcare providers, including but not limited to:

• General dental – check-ups, examinations, x-rays, scale and cleans, fillings
• Major dental – crowns, bridges, dentures, wisdom teeth removal, veneers, surgical tooth extractions
• Orthodontic – braces, Invisalign, retainers (including fitting and adjustment)
• Endodontic – root canal therapy, gum treatment
• Optical – prescription eye glasses, contact lenses, prescription sunglasses
• Physiotherapy – sport or movement exercise therapy for muscles or post-operative treatment
• Remedial massage – sports or injury treatment, deep tissue massages
• Chiropractic – consultations, x-rays, back manipulation and spinal adjustments for musculoskeletal issues
• Podiatry – ingrown nails, bunions, corns, ankles and lower limbs (useful for sportspeople and those with walking disorders)
• Orthotics – shoe inserts/insoles to restore natural foot function
• Exercise physiology – the use of clinically prescribed exercises to rehabilitate and manage injuries, chronic conditions, disabilities and more
• Psychology – treatment from a psychologist to address mental and physical health issues (some policies only cover treatment from a clinical psychologist)
• Non-PBS pharmaceuticals – helps pay for prescription medicine not listed on the government’s Pharmaceuticals Benefits Scheme (PBS)
• Lifestyle – helps pay for approved courses to improve your lifestyle, including programs for quitting smoking, fitness classes, gym memberships or weight management courses
• Eye therapy – treatment or physical therapy for crossed eyes, lazy eyes and double vision
• Occupational therapy – treatment to train people with physical injuries or illness (e.g. re-learning to walk after an accident, restoring function in broken bones or torn limbs)
• Speech therapy – assessment and treatment to re-learn to speak after a stroke or to help people with speech disabilities or impediments
• Hearing aids – to purchase, repair or replace a device to correct a hearing impairment
• Dietician services – diet, nutrition, weight loss and disease management by a recognised dietician
• Health aids and appliances – c-pap machine, blood pressure monitors, crutches and glucose monitors for diabetes management
• Ambulance – depending on which state you live in, you may want to consider taking out ambulance cover. Ambulance cover is included on some health insurance extras policies and/or hospital policies; however, the type of ambulance cover can vary by policy and fund.

Lower-level basic extras policies may include (but aren’t limited to) cover for:

• General dental
• Physiotherapy
• Optical (dependent on provider).

Basic policies may be subject to combined group limits and typically cover a lower percentage of service costs, which is why they generally cost less and have lower premiums than higher-level extras policies.

Medium-level extras policies usually provide good value for money. These policies will typically include (but aren’t limited to) cover for:

• General dental
• Major dental
• Endodontics.

These policies will also typically include some of the following:

• Orthodontics
• Optical
• Non-PBS pharmaceuticals
• Physiotherapy
• Chiropractic/osteopathy
• Podiatry
• Psychology
• Hearing aids.

Medium-level policies typically have higher annual limits than basic policies, but aren’t as high as comprehensive policies.

Comprehensive extras are the most expensive out of the three levels, but will cover the widest range of healthcare services, have the highest limits and pay the highest percentage of service costs. Top-level comprehensive policies usually include (but aren’t limited to) cover for:

• General dental
• Major dental
• Endodontic
• Orthodontic
• Optical
• Non-PBS pharmaceuticals
• Physiotherapy
• Podiatry
• Psychology
• Acupuncture

Some health funds and their policies cover a percentage of the costs associated with your treatment. For example, your policy may cover up to 60% of your dental costs up to the annual limit, and you’ll have to pay the other 40% as an out-of-pocket cost, known as the gap payment.

Alternatively, your policy may cover 100% of the costs of listed items (like glasses), although this will likely still be subject to an annual limit.

Some extras health insurance policies will have a dollar limit on how much you can claim per service, applied either annually per policy, up to the group limit and sub-limit or per visit or item.

Most limits on your extras policy will renew every year. This will either be on a membership, financial or calendar year, depending on the fund you’re with. Read your policy documents or contact your insurer for this information, as it can vary between services, policies and providers.

In terms of your health insurance extras benefits, you can either:

• Claim benefits on the spot by swiping your health insurance membership card at service providers that have a HICAPS terminal
• Claim benefits online (and in some instances through your fund’s mobile app) and be reimbursed after you’ve paid for your service. Ensure that you keep any receipts as your health fund may request this as proof of claim
• Claim benefits by visiting your health fund’s nearest branch, keeping in mind that not all health funds have branches

Extras-only health insurance generally costs less than a hospital insurance policy. However, your extras cover premiums do depend on which level of extras you get and who it covers. For example, extras policies that cover a variety of services with high limits will command a higher premium, while lower-level policies may cost less. If eligible, you may also be able to lower your costs by applying the Australian Government Rebate to your premiums.

Also, family extras cover will naturally cost more than single policies, as it will cover more people.

We’ve compiled some example prices below to give you an idea of how much extras cover may cost. Remember, your actual costs will vary depending on your circumstances and needs.

Everyone’s needs and budgets are different, which means it’s hard to say which type of policy you should get, whether it’s a hospital, extras or a combined policy. A combined policy joins the two types of insurance – hospital and extras – under one policy, so you can be treated both in and out of hospital by a range of healthcare providers.

If you want to keep on top of your health, extras can provide benefits for preventative and ongoing treatment. However, you may be more concerned about the cost of in-hospital surgeries (like knee replacements), in which case hospital insurance might be your preference.

However, you don’t necessarily have to choose one or the other. If a combined hospital and extras policy is within your budget, it can give you the benefits of both types of health insurance. A combined policy can also give you the peace of mind that you won’t have to pay for all of your healthcare when the time comes.

A standalone extras policy won’t exempt you from the Medicare Levy Surcharge (MLS). The MLS is a surcharge to high-income earners who don’t hold an eligible hospital insurance policy, designed to encourage them to use the private health system.

If you want to avoid the MLS, you’ll need to take out eligible hospital cover and hold it for the entire financial year. However, if you still want the benefits of extras cover, you can take out a combined hospital and extras policy.

Extras health insurance policies will typically have waiting periods for new members or those upgrading their cover, varying from two months to three years or more depending on the service and the health fund.

The Commonwealth Ombudsman outlines examples of typical waiting periods for some services in the table below.¹

Unlike waiting periods for hospital benefits, which the government sets, health insurance providers set extras waiting periods themselves and can make waiting periods as long as they want (within reason).

However, you can potentially shorten your waiting period or get extras cover with no waiting period for particular services. Some health funds or policies allow you to start claiming on select extras services straight away with no waiting period, while some have promotions from time to time that waive some extras cover waiting periods to attract more members.

However, waivers usually only occur on certain policies or services (e.g. health funds may have promotions that waiver the two- or six-month waiting periods on included extras).

Some of the extras services that may waive waiting periods include:

• General dental
• Physiotherapy
• Chiropractic
• Natural therapies.

That said, you’re unlikely to get waiting periods waived on more expensive services like major dental or orthodontics.

While you may have longer waiting periods on hospital cover with a pre-existing condition, this rule doesn’t apply to extras cover. This means that standard waiting periods will apply to your extras cover, even with a pre-existing condition.

In fact, there are extras health insurance policies for singles, couples, families and single parents. Health insurance for families will allow you to include your dependent children on your policy. Depending on your health fund and situation, they may be able to stay on your policy until they are 31.