If you hold private health insurance and live around Knoxfield, Ferntree Gully, Rowville, Wantirna, Scoresby, Boronia or Bayswater, you have probably wondered how your dental health fund extras actually work at the dentist. This is a plain-English explanation of the mechanism, so you know what to ask and what to expect before treatment.

Hospital cover is not extras cover

Private health insurance in Australia is split into two very different products. Hospital cover pays for treatment as an admitted patient in hospital. Extras cover, sometimes called general treatment cover, pays benefits towards services outside hospital such as dental, optical, physiotherapy and remedial massage.

Routine adult dental care is not covered by Medicare. Eligible children can get some dental covered through the Child Dental Benefits Schedule, but adults generally need private extras cover, pay privately, or a mix of both. So when you come in for a check-up, clean, filling or crown, the benefit side of the equation comes from your extras policy, not from Medicare.

A simple rule to start with: if you are not being admitted to hospital, your dental claim sits under extras.

How a dental extras policy is built

Funds divide dental treatment into categories, and each category usually has its own annual limit. The most common split is general dental and major dental.

General dental typically covers check-ups, cleans, examinations, X-rays and small fillings. Major dental usually covers crowns, bridges, dentures, more complex root canal treatment and sometimes surgical extractions. Orthodontics is often a third category, separate again, with its own lifetime or annual limit.

Because the categories are separate, you might have plenty of general dental benefit left but very little major dental benefit. That is why a clean can be well covered while a crown is not. Knowing which category your treatment falls into is the first step in understanding your rebate.

The fund pays a benefit per item number

Every dental procedure has an item number. A check-up is one item number, a scale and clean is another, a single-surface filling on a back tooth is another again. Your fund sets a benefit for each item number on your policy.

That benefit might be a set amount or a percentage of the fee. Either way, the amount you get back is determined by your policy and your level of cover, not by the dentist. Two patients sitting in the same chair having the same filling can receive very different rebates because their policies differ.

This is the part that surprises people most. The dentist’s fee is one number, the fund benefit is another, and the gap is what you pay. A higher level of extras cover generally means a higher benefit, but it also usually means a higher premium.

Annual limits and which year applies

An annual limit is a cap on how much your fund will pay towards a category, or sometimes towards extras overall, in a defined period. Once the limit is reached, you pay the full fee for further treatment in that category until the limit resets.

The reset date depends on your fund. Some run on the calendar year, some on the financial year, and some on your membership year, which starts on the anniversary of when you joined. If you are planning a crown or a course of treatment, it is worth checking which year your fund uses, because timing can affect how much benefit is available.

You can usually see your remaining limits in your fund’s app or by ringing the fund. A two-minute call saves the guesswork.

Waiting periods and switching funds

New extras policies come with waiting periods. You generally cannot claim straight away. Waiting periods are usually shorter for general dental and longer for major dental and orthodontics. If you upgrade your level of cover, a waiting period often applies to the higher benefits.

If you are thinking about switching funds, ask both the old and new fund whether your previous cover counts towards your waiting periods. Sometimes it does, sometimes it does not, and it depends on the fund and the history of your cover. Getting this in writing before you switch avoids nasty surprises.

If you are already a patient with us and change funds, let the front desk know so your records are updated.

Claiming on the day with HICAPS

HICAPS is the electronic claiming terminal you will find at many dental practices. You bring your fund card, we swipe it at the front desk, the benefit is calculated instantly and comes off your fee. You pay only the gap, if there is one.

If for some reason the claim cannot go through HICAPS, you pay the fee and we give you an itemised receipt with the item numbers. You then claim from your fund yourself, either through the app, online or by post. Keep the receipt until the claim is processed.

At Knoxfield Dental Care we have HICAPS on-site, so most patients claim on the day without paperwork.

• Bring your private health fund card to every appointment.
• If you have more than one policy, tell the front desk which one to claim against.
• Ask for an itemised receipt if you need to claim manually.

Finding out what you will get back before treatment

The most reliable way to know your rebate is to ask us for a written treatment plan with the item numbers, then ring your fund or check its app with those numbers. The fund can tell you the benefit it will pay for each item and how much of your annual limit is left.

Do this before booking larger treatment. It takes a few minutes and turns a vague estimate into a real number.

We also have payment plans and options such as Afterpay for the gap on larger treatment. Ask at reception if you would like to spread the cost.

The no-gap check-up and clean at Knoxfield Dental Care

Patients with dental extras cover that pays at least a partial benefit for the relevant items can have a no-gap check-up and clean. That means no out-of-pocket cost for those eligible items when the fund benefit covers them.

The package includes a comprehensive exam, clean and polish, fluoride, X-rays as needed and an OPG, which is a full-mouth X-ray, if needed, plus a treatment plan. It is available up to two times per calendar year or financial year, or as the fund’s benefits allow.

Eligibility still depends on your fund, your level of cover, your remaining annual limit, waiting periods and clinical need. If your fund pays nothing for the treatment, or your limit has been reached, the normal fees are payable on the day.

A deeper or more extensive clean for heavy build-up or gum disease is not part of the no-gap offer, and fillings or other treatment are separate. We accept most major Australian private health funds; HCF, Bupa and Medibank are among the funds our patients hold. What comes back on the day depends on your policy.

This article by Knoxfield Dental Care is general information only and not a substitute for personalised dental advice. Please book a consultation for advice specific to you.