If you have private health insurance with extras cover, part of every dental visit may already be paid for. Yet many people don’t know what their policy actually covers until they’re standing at reception. This guide explains how dental extras work in Australia, what “no gap” really means, and how to avoid paying more than you need to.
Hospital cover vs extras cover
Private health insurance in Australia comes in two parts. Hospital cover helps with the cost of treatment as an admitted patient in hospital. Extras cover (sometimes called general treatment or ancillary cover) helps with services outside hospital, such as dental, optical and physiotherapy.
Almost all everyday dentistry, from check-ups to crowns, is claimed under extras. Medicare doesn’t cover most dental treatment for adults, so extras cover is how most people reduce their dental costs.
General dental vs major dental
Funds usually split dental benefits into two groups:
- General (preventive) dental: check-ups, scale and clean, x-rays, fluoride, and often simple fillings and extractions
- Major dental: crowns, bridges, dentures, root canal treatment, implants and oral surgery. Orthodontics is often a separate category with its own limit
Basic extras policies may only include general dental. Mid and top-level policies usually add major dental and orthodontics, often with higher annual limits.
Annual limits
Each policy sets a maximum amount the fund will pay for each category in a year, per person. Once you reach the limit, you pay the full fee until it resets. Some limits are combined across several services, while others are separate for general dental, major dental and orthodontics.
Limits reset either on 1 January or on 1 July, depending on your fund and policy. If you haven’t used your dental benefits this year, it’s worth booking before they reset, because unused limits generally don’t carry over.
Waiting periods
When you take out a new policy or upgrade your cover, you usually have to wait before you can claim. Waiting periods for general dental are commonly a couple of months, while major dental and orthodontics often carry waiting periods of a year. Your fund will confirm the exact periods for your policy. If you switch funds at the same level of cover, waiting periods you’ve already served usually carry across.
Item numbers: how dental claims work
Every dental service has an item number from the Australian Schedule of Dental Services and Glossary. Your fund pays a benefit for each item number, not for the visit as a whole. A typical check-up and clean might include:
- 011 or 012: comprehensive or periodic oral examination
- 022: intraoral x-ray (per film)
- 114: removal of calculus (the “scale” in scale and clean)
- 121: topical fluoride application
If you’re planning larger treatment, ask us for a written quote listing the item numbers. You can then call your fund and ask exactly how much they’ll pay back for each item before you go ahead.
What “preferred provider” means
Many funds have agreements with dental practices called preferred provider or member-choice arrangements. The fund and the practice agree on fees for common services, which usually means a higher benefit for you and a smaller gap, sometimes none at all for check-ups and cleans.
Hornsby Dental is a preferred provider with Bupa, Medibank, nib and Westfund. If you’re with another fund, you can still claim; your benefit just depends on your policy.
What “no gap” actually means
The “gap” is the difference between the fee and what your fund pays. A no-gap check-up means the fund’s benefit covers the whole fee, so you pay nothing on the day for those items. Whether you’re eligible depends on your fund, your level of cover, whether you’ve served waiting periods and whether you have limits left for the year.
At Hornsby Dental, our new patient check-up and clean (examination, scale and clean, x-rays and fluoride) is $219, or No Gap with eligible health fund extras.
Claiming on the spot with HICAPS
We process claims at the time of your visit with HICAPS. You swipe your health fund card, the fund approves the claim in seconds, and you only pay any gap. There’s no paperwork to send in afterwards.
Five ways to get more from your extras
- Book your check-up every six months. Many policies cover two preventive visits a year. Using them catches problems while they’re small and cheap to fix.
- Check your remaining limits in your fund’s app before booking larger treatment.
- Ask for item numbers and confirm your benefit with your fund before major work.
- Think about timing. If treatment can safely be split, part of it before your limits reset and part after can mean two years of benefits.
- Review your cover each year. If you’re planning orthodontics or crowns, a policy with higher major dental limits may be worth it, but check the waiting periods first.
A worked example
Here’s how a year of dental care might play out for someone with mid-level extras cover. The numbers are illustrative only; your own benefits depend on your fund and policy.
- March: a check-up and clean. As a preferred provider visit, the fund’s benefit covers the fee, so there’s no gap.
- June: the dentist finds a small cavity between two teeth on an x-ray. A filling is done at the next visit. The fund pays part of the fee from the general dental limit, and the patient pays the gap.
- September: a second check-up and clean, again with no gap.
- November: an old, cracked filling needs replacing with a crown. Major dental has a separate annual limit. The patient checks the remaining limit in the fund’s app, asks for the item numbers, and books the crown before the limit resets.
Because the small cavity was found early on an x-ray, it needed only a filling. Leaving it for a few more years could have meant a root canal and a crown, at many times the cost.
Common mistakes that cost money
Waiting until something hurts
Pain usually means a problem has been developing for some time. Decay, gum disease and cracked teeth are cheaper and simpler to treat when they’re found at a routine visit.
Letting limits lapse
If you pay for extras but never claim, you’re paying for benefits you don’t use. Two preventive visits a year is how most people get value from their cover.
Upgrading just before big treatment
Upgrading your cover to pay for crowns or orthodontics next month rarely works, because higher benefits usually come with new waiting periods. Plan ahead if you know treatment is coming.
Assuming all funds pay the same
Benefits for the same item number vary a lot between funds and policies. Check your own policy, not what a friend received.
Not asking for a quote
For anything beyond a check-up, a written quote with item numbers lets you confirm your benefit and plan your budget before you commit.
If you don’t have extras cover
You can still see us without insurance. Our price list shows typical fees, and we’ll always give you a written estimate before treatment. For larger treatment, ask about payment options.
Health fund FAQs
Do I need my card at the appointment?
Yes, bring your physical card or a digital card from your fund’s app so we can claim through HICAPS.
Can I claim for my children on my policy?
If your children are on your family policy, yes. Each person usually has their own limits within the policy.
Why did my friend pay nothing and I paid a gap?
Benefits differ between funds, policy levels and preferred provider arrangements. Two people having the same treatment can receive different benefits.
Can I get an estimate before treatment?
Yes. Ask for a written quote with item numbers, then check with your fund. We’re also happy to run an estimate through HICAPS where your fund supports it.
See our health funds page for more, and our price list for common fees.
Find out more about no gap dental offer in Hornsby.
Book a visit at Hornsby Dental
Hornsby Dental is at Suite 21, 14 Edgeworth David Avenue, Hornsby, about three minutes’ walk from Hornsby Station, with free street parking nearby. We’re open Monday to Friday 9am–6pm and Saturday 8:30am–4pm. Book online or call (02) 8090 1100.
This article is general information only. It isn’t a substitute for advice from your dentist about your own mouth and health.