Extras Cover Health Insurance

General dental covers routine preventative and basic restorative work like check-ups, cleans, x-rays, fillings, and fluoride treatments. Waiting periods are typically 2 months.

Major dental covers more complex and expensive procedures like crowns, root canals, bridges, dentures, and extractions. These services have 12-month waiting periods and higher costs, so they're placed in a separate category with their own annual limits.

Most extras policies have separate limits for general and major dental—for example, $800/year for general and $1,200/year for major. The limits don't combine; you can claim up to both amounts if you need services from both categories.

Annual limits are the maximum amount you can claim per service category each year (usually calendar year or policy anniversary). Once you reach the limit, you pay 100% out-of-pocket for any additional services in that category until the limit resets.

Example: Your optical limit is $350/year with 100% benefit. You buy glasses for $400 in March. The insurer pays $350; you pay $50. If you need new glasses in July (same year), you pay 100% out-of-pocket because you've exhausted your $350 limit. In January, your limit resets and you can claim again.

Tips:

• Plan expensive services (e.g., glasses, major dental) around your limit reset date
• Some policies offer "rollover" or "carry forward" of unused limits—check your PDS
• Limits apply per person on family policies, so each dependent has their own limits

Most extras services have 2-month waiting periods for general services (dental check-ups, optical, physio) and 12-month waiting periods for major services (major dental, orthodontics).

Waiting periods by service:

• 2 months: General dental, optical, physiotherapy, chiropractic, podiatry, remedial massage, psychology (most services)
• 6-12 months: Major dental, orthodontics, some natural therapies

After the waiting period ends, you can claim immediately. For example, if you join extras cover on January 1st, you can claim on general dental from March 1st onward.

Tip: If you're switching insurers, some allow you to transfer waiting periods already served with your previous insurer, so you don't restart from zero.

No, you generally don't need a referral to claim on extras cover. You can visit any provider (dentist, optometrist, physiotherapist, etc.) directly and claim through your insurer.

However, you should:

• Check if your provider is part of the insurer's preferred network (you may get higher rebates or no-gap services)
• Confirm the provider is registered/qualified (e.g., physiotherapists should be registered with AHPRA)
• Keep receipts and invoices for claims

Some insurers have "dental networks" or "optical partners" where you can get on-the-spot claims with reduced or no gaps. Ask your insurer about preferred providers.

Waiting periods prevent people from joining extras cover, claiming immediately for expensive procedures, and then canceling.

2-month waiting periods apply to routine, preventative, and lower-cost services where the risk of "adverse selection" (people joining just to claim) is lower:

• General dental (check-ups, cleans, fillings)
• Optical (glasses, eye tests)
• Physiotherapy, chiropractic, podiatry
• Psychology, remedial massage

12-month waiting periods apply to high-cost procedures where people might otherwise join only when they need treatment:

• Major dental (crowns, root canals, dentures)
• Orthodontics (braces)
• Some natural therapies

The longer waiting period ensures people maintain cover long-term rather than using it as "on-demand" insurance.

Most insurers offer multiple claiming options:

1. HICAPS at point of service (instant claim): Many dental, optical, and allied health providers have HICAPS terminals. You swipe your health insurance card, pay the gap on the spot, and the provider claims the benefit directly from your insurer.

2. Mobile app claim: Take a photo of your receipt and submit through your insurer's app. Claims are usually processed within 2-5 business days.

3. Online portal: Upload receipts through your insurer's website member portal.

4. Mail or email: Send receipts and claim forms to your insurer (slowest method).

What you need:

• Valid receipt showing: provider name, date of service, service description, item codes (if applicable), cost
• Your membership number
• Patient name (if claiming for a dependent)

Processing time: HICAPS is instant; app/online claims typically 2-5 business days; mail claims 1-2 weeks.

Yes, you can generally visit any registered provider and claim on your extras cover. However, using your insurer's preferred provider network often results in:

• Higher benefits – Some insurers offer 80-100% back at preferred providers vs. 60% elsewhere
• No-gap or reduced-gap services – Pay little to nothing for services within limits
• On-the-spot claiming – HICAPS terminals for instant processing

Check your insurer's provider network:

• Bupa: Members First Network
• HCF: More for You Network
• nib: First Choice Network
• Medibank: Members' Choice Advantage

Non-preferred providers: You can still claim, but you may receive lower benefit percentages and have higher out-of-pocket costs.

It depends on your usage. Do a break-even analysis:

Calculate your annual extras costs without insurance:

• 2 dental check-ups: $300-400
• 1 pair of glasses: $300-500
• Occasional physio or massage: $200-400
• Total: $800-1,300/year

Compare to extras premium:

• Basic extras: $15-20/week = $780-1,040/year
• Mid extras: $20-30/week = $1,040-1,560/year

If your annual costs exceed the premium, extras cover saves money. Even if costs are similar, extras cover provides:

• Predictable budgeting (fixed weekly cost vs. unpredictable bills)
• Encouragement for preventative care (more likely to get regular check-ups)
• Protection against unexpected costs (injury requiring physio, dental emergency)

Singles who benefit most:

• Wear glasses or contacts
• Visit the dentist 2+ times per year
• Receive ongoing allied health treatment
• Play sports or have active lifestyles

Singles who may not need it:

• Rarely visit dentists or optometrists
• Have excellent dental health and vision
• Prefer to self-insure for occasional costs

Optical extras typically cover:

Prescription eyewear:

• Prescription glasses (frames + lenses)
• Prescription sunglasses
• Contact lenses (daily, monthly, yearly)
• Lens coatings (anti-glare, blue light, transitions)

Eye examinations:

• Comprehensive eye tests
• Visual field tests
• Retinal photography

What's NOT covered:

• Laser eye surgery (LASIK, PRK) – usually excluded as it's elective
• Non-prescription sunglasses
• Reading glasses (non-prescription)
• Cosmetic frames without prescription

Annual limits: Typically $200-600/year depending on coverage level Benefit percentage: Usually 80-100% Waiting period: 2 months

Example claim: You buy glasses for $450. Your optical limit is $400 with 100% benefit. You claim $400; you pay $50 out-of-pocket.

You can purchase extras as:

1. Standalone extras cover – Extras only, no hospital component
2. Combined hospital + extras – Both in one policy

Benefits of combined policies:

• Cost savings: Usually 5-10% cheaper than buying separately
• Single premium payment: One bill instead of two
• Simplified management: One policy, one insurer, one app
• Package deals: Some insurers offer better value on combined policies

When to buy separately:

• You only need extras cover (young, healthy, below MLS threshold)
• You want different insurers for hospital and extras (comparing best value)
• You already have hospital cover and want to add extras later

Most Australians choose combined policies for convenience and savings, especially if they're already paying for hospital cover to avoid the Medicare Levy Surcharge.

Cost comparison example:

• Hospital cover alone: $60/week
• Extras cover alone: $25/week
• Total separate: $85/week vs.
• Combined hospital + extras: $78/week
• Savings: $7/week ($364/year)