A Practical Guide to Dental Benefits in Private Health Funds

Dock Dental Team  |  March 18, 2025  |  4 min read

How Dental Benefits Work in Private Health Funds

Dental benefits are typically part of Extras Cover, a category of private health insurance that focuses on non-hospital services like dental, optical, and physiotherapy. This is normally separate to the Hospital cover you might have taken. Here’s a breakdown of how the Extras benefits operate:

Rebates

Health funds generally cover a percentage of the cost of dental services, known as a rebate. The rebate percentage varies depending on the type of service and the level of coverage you select. Within the percentage rebate, most policies also have a maximum rebate amount payable for each type of treatment. In general, health funds pay the lower among these two amounts.

Gap Payments

As you may only get a percentage of the dental fees in rebates, you will still need to pay the difference between what the dentist charges and what the fund covers. This is commonly called a gap fee or out of pocket cost.

You can ask your dentist to check on the rebates before you start the treatment to get an estimate of your out of pocket cost. This is known as a Quote, where you will be provided total billable fee, health fund rebate and gap fee.

Limits

Most health funds set a yearly cap on how much they will pay for dental services in a year, called Annual Limit. Once you reach this limit for the year, health funds will not provide any dental benefit until the limit resets the following year. Most of the health funds reset on January 1st each year; others might reset based on your sign up date or financial year.

They might also have a Lifetime Limit on certain treatments like orthodontics. In those cases, the health fund will stop covering such treatments once you reach the limit. Unlike the annual limits, these limits do not reset the following year.

Waiting Periods

Most funds require you to wait a certain period after your sign up, before you can claim dental benefits. General dental services, such as check-ups and cleanings, often have a waiting period of 2–6 months, while major dental procedures, like crowns or bridges, may require a 12-month wait.

Check your health fund rebates

Already have a health fund cover but do not know how much it would cover? Please feel free to drop in to our clinic with your health fund card for an obligation free check.

We will be able to provide you a quote with your rebates for regular dental or any other treatment you are seeking. It will only take a few minutes and appointments are not needed.

Types of Dental Services Covered

Private health funds typically categorise dental services into three main types, each with different levels of coverage:

General Dental

This includes routine and preventive services such as check-ups, cleanings, fillings, and X-rays. Most policies cover a significant portion of these costs, but can vary between health funds and their packages.

Major Dental

This covers more complex and costly procedures like root canals, crowns, bridges, dentures, and gum treatments. Rebates for major dental work are usually lower in percentage compared to the general dental. This too can vary between health funds and their packages.

Orthodontic Treatment

This includes braces, aligners and other corrective treatments for misaligned teeth. Orthodontic benefits often come with separate annual and lifetime limits.

What to Compare When Choosing Dental Cover

Selecting the right dental cover requires careful consideration to ensure you’re getting the best value for your needs. You should always compare premiums against the level of coverage provided. A cheaper policy might seem a good value but might have lower annual limits or rebates, making it less cost-effective in the long run. Here are some key factors to keep in mind:

1. Annual Limits

Check the annual limit for dental services. In general, General dental and Major dental have separate limits. If you anticipate needing significant dental work, you will be safer choosing a policy with a higher Major dental limit. If you only require regular dental checkup and cleans, opting for one with higher limit for General dental might be more beneficial.

Some funds combine limits for all extras services (e.g., dental, optical, physiotherapy). You must evaluate your needs properly before taking up such policies. Depending upon how frequently you use each of those services, it may or may not be the most beneficial one for you. For example, if you do not wear glasses and have a good muscle health, you might be able to use most of your limit for dental which will give you the best value. However, if you wear glasses or frequently use physiotherapy sessions, you might not have much limit left for dental needs.

2. Rebate Percentages

Compare the percentage of costs covered for general and major dental services. Higher rebates mean lower out-of-pocket expenses. Be aware that some funds may offer 100% coverage for regular dental such as check-ups and cleans but significantly lower rebates for major procedures. Depending upon your dental health, you can opt for what’s more important for you.

3. Limits for Individual Item Numbers

Besides the percentage rebate, some health funds impose limits on specific dental procedures, known as item numbers. For example, a policy might cover a fixed amount (in dollars) for a checkup, regardless of the total annual limit. This means that even if you haven’t reached your annual limit, you may still get a lower rebate than the rebate based on percentage. Always check the fund’s schedule of benefits to understand where these limits override the percentage rebate.

4. Waiting Periods

Ensure you understand the waiting periods for general and major dental services. If you need immediate treatment, look for funds with shorter waiting periods. Some funds offer promotions or waive waiting periods for new members, so it’s worth exploring these options too.

5. Lifetime Limits

Orthodontic treatments often have lifetime limits as well as annual limits. You might have a higher lifetime limit but the annual limit might restrict you from using all of it in one go. While this might not be a problem for long term braces or aligner treatments, you might not be able to get the full benefit for short term aligner treatments. Ensure this aligns with your needs, especially if you’re considering aligners and braces for yourself or your family.

6. Exclusions and Restrictions

Some policies exclude certain treatments, such as cosmetic dentistry (e.g., teeth whitening).  Orthodontics are not included in all policies. Make sure you read the fine print to understand what’s covered and what’s not and evaluate it based on your family’s upcoming dental needs.

This guide from Australian Government can help you compare different health fund policies in terms of the benefits available. However, be sure to read the fine prints on policy details before you decide.

Tips for Maximising Your Dental Benefits

To get the most out of your dental cover, consider these practical tips:

1. Use Your Annual Limit Wisely

Schedule treatments strategically to make the most of your annual limit. For example, if you are near your limit, consider delaying non-urgent procedures until the next calendar year. At the same time, if you have limits near the end of the year, schedule the treatments you have been delaying on before the limit resets. Working this way can save you from running out of limits for necessary treatments or missing out on a huge unused benefit.

2. Focus on Preventive Care

Regular check-ups and cleanings can help you avoid costly major dental work down the line. Most policies cover preventive care at a high rebate percentage, so take advantage of this. You can even opt for policies which cover full cost of  2 preventive visits per year. You might pay a slightly higher premium but will save on out of pocket expenses.

3. Review Your Policy Annually

Your dental needs may change over time, so review your policy each year to ensure it still meets your requirements. For example, if your children need orthodontic treatment, you may want to switch to a policy with higher orthodontic limits. Similarly, if you have been delaying a certain treatment due to cost, it might be worth to switch to a policy with higher Major dental cover to save on gap payment.

4. Plan for Major Dental Work

If you know you’ll need major dental work, discuss with your dentist how you can spread it across so that you get the best benefit out of your cover. Many non-urgent care can be planned in steps so that you can use your annual limits to provide best value. Some treatments like dental implants can be planned, so that you can use your limit for implant in current year and plan the crown for next year. Timing it correctly for your orthodontic treatments can also reduce your out of pocket costs.

5. Do not decline treatments without checking your rebates

While cost of some dental treatments might not be within your planned budget, never decline the treatment in first instance. Always make sure that you work with the dental team to evaluate your health fund benefits. Sometimes, it might surprise you with a much larger benefit than that you were expecting.

6. Keep Track of Claims

Monitor your claims throughout the year to ensure you’re staying within your annual limits and maximising your rebates. Most of the private health fund providers have apps or customer websites to check on your limits and usage. Be sure to check the limits left before you book your next appointment. It is also helpful to have it handy when you are discussing costs with your dentist.

Dental benefits in Australian health funds are a valuable tool for managing the cost of dental care. By understanding how these benefits work, the types of services covered, and what to look for in a policy, you can make informed decisions that save you money and ensure access to quality dental care. Pay close attention to annual limits, rebate percentages, waiting periods, and limits for individual item numbers to avoid unexpected costs. With the right approach, you can maximise your dental benefits and keep your smile healthy for years to come. If you need any help in figuring out your benefits, feel free to reach out to our team members and they can help you check your benefits.

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