Extras cover in Australia can be a bit of a puzzle. Many people pay premiums year after year without fully understanding what they’re entitled to or how to maximize their benefits. This guide aims to demystify extras cover, providing you with actionable tips and real-world insights to help you make the most of your health insurance.
Understanding the Basics of Extras Cover
Extras cover, also known as ancillary or general treatment cover, complements your hospital cover by helping to pay for services Medicare doesn’t typically cover. These often include things like dental, optical, physiotherapy, and other allied health services. The specific services and the amount you can claim back vary depending on your policy and the health fund you’re with.
What is Typically Included? Common inclusions in extras cover may include:
- Dental (general, major, and sometimes orthodontics)
- Optical (glasses, contact lenses)
- Physiotherapy
- Chiropractic
- Massage therapy
- Psychology
- Acupuncture
- Hearing aids
- Podiatry
- Dietetics
- Speech therapy
Keep in mind that not all policies are created equal. A basic extras cover might only include general dental and optical, while a comprehensive policy could encompass a broader range of services with higher claim limits.
Decoding Your Policy: Understanding Limits, Waiting Periods, and Exclusions
Before diving into how to maximize your benefits, it’s crucial to understand the fine print of your policy. This involves paying close attention to annual limits, waiting periods, and exclusions.
Annual Limits: This is the maximum amount your health fund will pay for a particular service within a year. For example, your policy might have a $500 annual limit for general dental. Once you’ve claimed that amount, you won’t be able to claim any further dental expenses until the next policy year. Some policies have sub-limits within a category, further restricting the amount you can claim for specific treatments.
Waiting Periods: These are periods you need to wait after joining a health fund (or upgrading your policy) before you can claim benefits for certain services. Waiting periods are designed to prevent people from joining a fund, claiming for expensive treatments, and then immediately cancelling their policy. Generally, waiting periods are shorter for general dental and optical, while major dental, orthodontics, and some other services often have longer waiting periods, sometimes up to 12 months. According to the Private Health Insurance Ombudsman, understanding waiting periods is essential to avoid unexpected out-of-pocket expenses.
Exclusions: Some extras policies might exclude specific treatments altogether. For example, a policy might not cover cosmetic dental procedures or certain alternative therapies. Make sure you are aware of any exclusions within your policy. Often, policies are tiered and sold as Bronze, Silver, or Gold extras, each with their set of inclusions, exclusions, and annual limits.
Example: Sarah joins a new health fund with an extras policy. She needs major dental work costing $2,000. Her policy has a 12-month waiting period for major dental. If she gets the work done before the 12 months are up, she won’t be able to claim anything. If she waits until after the 12-month waiting period, she can claim up to her annual limit for major dental, after applying any co-payment.
Maximize Your Extras Cover: Actionable Tips and Strategies
Now that you understand the basics, let’s delve into how to get the most out of your extras cover:
1. Utilize Preventive Care: Many extras policies offer benefits for preventive dental care, such as check-ups and cleanings. Regular check-ups can help detect and address minor dental problems before they become major (and expensive) issues. Taking advantage of these benefits not only keeps your teeth healthy but also helps you maximize your policy.
Example: David’s extras policy covers two dental check-ups and cleans per year. He makes sure to book these appointments to maintain his oral health and claim the benefits provided.
2. Coordinate Treatments and Claims: Plan your treatments strategically throughout the year to maximize your annual limits. If you know you’ll need multiple treatments (e.g., physiotherapy and dental work), try to spread them out across the year to avoid exceeding your limits for any one service. Keep records of your treatments and receipts to ensure accurate claims processing.
3. Understand Benefit Rollovers: Some, but not all, extras policies offer benefit rollovers. This means that if you don’t use your entire annual limit for a particular service in one year, a portion of it might roll over to the next year. Check your policy details to see if this is an option. Understanding this feature is key as it can significantly increase your available funds for future treatment. For example, BUPA offers potential rollovers on certain extras, so check with your fund directly.
4. Shop Around for Providers: Different healthcare providers charge different fees for the same services. Before committing to a particular provider, do some research and compare prices. Consider providers within your health fund’s network, as they often offer discounted rates. Also, some health funds, such as HCF, have their own dental and optical centers that may provide better value.
5. Take Advantage of Member Discounts: Many health funds offer member discounts on other products and services, such as gym memberships, travel insurance, and retail purchases. Check your health fund’s website or app for a list of available discounts and promotions. These discounts can provide additional value beyond just healthcare benefits.
6. Review Your Policy Annually: Your healthcare needs may change over time. It’s a good idea to review your extras cover annually to ensure it still meets your needs. If your needs have changed (e.g., you now require more physiotherapy or psychology), consider upgrading your policy to a more comprehensive one. Conversely, if you’re not using certain benefits, you might be able to downgrade to a cheaper policy.
Case Study: Maria had an extras policy that included optical benefits. However, she hadn’t worn glasses in years and was paying for a benefit she wasn’t using. After reviewing her policy, she downgraded to a basic extras cover, saving hundreds of dollars per year. She now spends what she saves each year on alternative therapies, such as acupuncture and remedial massage.
7. Understand the Difference Between Percentage and Fixed Benefits: Some policies pay a percentage of the cost of a treatment (e.g., 60% of the dental fee), while others pay a fixed dollar amount (e.g., $50 per physiotherapy session). Understand which type of benefit your policy offers, as this can impact your out-of-pocket expenses. Percentage-based benefits are often better for more expensive treatments, while fixed benefits can be more predictable for routine services.
8. Use Extras for Family Members: If your policy covers your family, make sure all eligible family members are utilizing their benefits. Children often require dental and optical care, and adults may benefit from physiotherapy or other allied health services.
9. Claim Online or Through the App: Many health funds offer convenient online or mobile app claiming options. These methods are often faster and more efficient than paper-based claims. You can typically submit your claims by uploading a photo of your receipt. Some providers also offer HICAPS (Health Industry Claims and Payments Service), which allows you to claim your benefits on the spot.
10. Stay Informed About Policy Changes: Health funds often make changes to their policies, including benefit levels, waiting periods, and exclusions. Stay informed about these changes by reading your health fund’s newsletters, visiting their website, or contacting them directly. This will help you avoid surprises and ensure you’re always getting the most out of your cover.
11. Making a Complaint: The Private Health Insurance Ombudsman (PHIO) is a free, independent service that helps resolve disputes between consumers and private health insurers. If you have a complaint about your extras cover, such as a denied claim or a disagreement about policy terms, you can contact the PHIO for assistance. It’s a good idea to first try to resolve your issue directly with your health fund. If that’s not possible, you can then take it to PHIO. Also, if you have a complaint about your health fund, you may be able to escalate the matter to the Australian Financial Complaints Authority (AFCA).
12. Understanding Premium Increases: Private health insurance premiums typically increase annually. Health funds tend to announce premium increases in early to mid-year, which then take effect from April 1. Be prepared for these increases and factor them into your budget. You can also use premium increases as an opportunity to review your policy and compare it with other options to ensure you’re still getting the best value for your money.
Specific Service Considerations
Let’s also consider specific services commonly covered under extras policies and how to maximize their specific benefits.
Dental: This is a very popular inclusion. Understand what is covered under “general dental” (check-ups, cleans, fillings) versus “major dental” (crowns, bridges, root canals) versus “orthodontics” (braces, aligners). Major and ortho will almost always have longer waiting periods. Many Australians require wisdom tooth removal; understand if/how your policy covers this. Look for “no gap” dental providers where you will have no additional costs on typical cleaning and check-up procedures.
Optical: Know the allowance per year and potentially per visit covered under optical extras. Factor in the cost of eye exams performed by the optometrist. For Australians who require progressively stronger prescriptions yearly, this is an important part of any extras cover. Some policies may also have benefits toward contact lenses in addition to or instead of glasses.
Physiotherapy: Consider the number of visits covered per year, and the gap fee you will pay per visit. Chronic ailments or sports injuries often require multiple sessions per week for extended periods. Factor this into the policy you choose if physiotherapy is likely needed in the future.
Mental Health (Psychology): Medicare provides some coverage for psychology visits under a Mental Health Treatment Plan obtained from your GP. Your extras cover can supplement this by providing additional sessions once your Medicare-funded sessions are exhausted. This benefit is extremely valuable for anyone needing ongoing mental health support. Telehealth (online) psychology sessions are increasingly common; check if your policy covers these.
The Impact of Age and Life Stage
Your healthcare needs, and therefore the most beneficial extras cover for you, will likely change over time. Consider this throughout different stages of your life.
Young Adults: In this stage, focusing on basic dental, physiotherapy (due to sports/activities), and potentially optical might be most useful. A lower-tier extras cover can suffice.
Families: Parents with young children will benefit from higher dental and optical cover for the kids. Pregnancy-related services sometimes have associated extras benefits, like rebates for birthing classes. Speech therapy and occupational therapy is common treatment for younger children should also be factored into considerations.
Middle-Aged Adults: This is where chronic disease management potentially becomes more important. Having extras cover with good rebates on physiotherapy, podiatry, and other allied health services can be highly beneficial. Psychology/mental health benefits may also become important during a stressful life stage.
Seniors: Dental health becomes increasingly important as we age, so consider an extras cover with a high annual dental allowance. Optical needs also increase, as do potential needs for hearing aids or other assistive devices. Additionally, benefits for podiatry, massage, and other therapies that can help manage pain and mobility are valuable.
Negotiating With Your Health Fund
Don’t be afraid to negotiate with your health fund. While you can’t negotiate the actual policy inclusions, you can negotiate on policy costs and potentially access better deals.
- Ask for Discounts: Loyalty discounts, corporate discounts (through your employer), or discounts for paying annually are sometimes available. Never hurts to ask!
- Threaten to Switch: Let your health fund know you’re considering switching to a competitor. They might offer you a better deal to retain your business.
- Lodge a Complaint: If you have had genuine service concerns (claim was incorrectly denied, prolonged wait times), lodging a formal complaint on your health funds’ internal review board might open up avenues for discounts.
Extras Cover vs. Hospital Cover: Knowing the Difference
It’s crucial to distinguish between extras cover and hospital cover, as they serve different purposes and often cause confusion. Hospital cover helps pay for your treatment as a private patient in a hospital, including accommodation, theatre fees, and doctor’s fees. Extras cover, on the other hand, covers out-of-hospital services like dental, optical, and physiotherapy. Some policies combine both hospital and extras cover, while others offer them separately. Consider your individual needs and budget when deciding whether to take out both types of cover.
Understanding Government Rebates and Incentives
The Australian government offers rebates to help offset the cost of private health insurance. The amount of the rebate depends on your income and age. Higher-income earners receive a lower rebate, while lower-income earners receive a higher rebate. The rebate is typically applied as a reduction in your premiums. The government also offers incentives to encourage people to take out private health insurance, such as the Medicare Levy Surcharge (MLS), which is an additional tax for high-income earners who don’t have private hospital cover.
Comparing Different Health Funds: A Practical Approach
Choosing the right health fund can be overwhelming, given the multitude of options available. Here’s a practical approach to comparing different funds: Review the comparison tools using websites such as the government’s Private Health Insurance Ombudsman.
- Define Your Needs: Start by identifying your healthcare needs and priorities. What services are most important to you (e.g., dental, optical, physiotherapy)?
- Compare Policies: Use online comparison tools to compare policies from different health funds. Pay attention to annual limits, waiting periods, exclusions, and premiums.
- Read Reviews: Check online reviews to get insights into the experiences of other members.
- Contact the Funds: Contact the health funds directly to ask questions and clarify any doubts you may have.
- Consider Value, Not Just Price: Don’t base your decision solely on price. Consider the overall value of the policy, including the benefits it offers and the service you receive.
The Future of Extras Cover: Trends and Innovations
The private health insurance industry is constantly evolving, with new trends and innovations emerging. Some current trends include:
- Telehealth: The rise of telehealth has led to increased demand for online consultations with healthcare professionals. Many health funds are now offering benefits for telehealth services.
- Wearable Technology: Wearable devices, such as fitness trackers and smartwatches, are becoming increasingly popular. Some health funds are partnering with wearable technology companies to offer incentives for members who achieve certain health goals.
- Personalized Health Plans: Some health funds are offering personalized health plans tailored to individual needs and preferences. These plans may include customized benefits and support programs.
- Preventive Care Focus: There is a growing emphasis on preventive care, with health funds offering more benefits for services that promote wellness and prevent illness.
FAQ: Your Burning Questions Answered
Let’s address some commonly asked questions about extras cover in Australia:
Q: What is the difference between a gap fee and an excess?
A: A gap fee is the difference between what your health fund pays and what the provider charges. An excess is a fixed amount you pay towards a hospital admission (and not extras) before your health fund starts paying.
Q: Can I claim extras benefits at any provider?
A: You can generally claim benefits at any provider, but you may get a higher benefit at providers who are part of your health fund’s network. These are referred to as ‘Members First’ or ‘Preferred Provider’ networks.
Q: Is it worth having extras cover if I’m young and healthy?
A: Even if you’re young and healthy, extras cover can be worthwhile for unexpected dental or optical needs. It can also encourage preventative care, such as regular dental check-ups.
Q: How do I know if a provider is part of my health fund’s network?
A: You can check your health fund’s website or app for a list of network providers. You can also ask the provider directly if they are part of your health fund’s network.
Q: What happens if I don’t use all of my annual limits?
A: In most cases, any unused annual limits are forfeited at the end of the policy year. However, some policies may offer benefit rollovers (check with your fund).
Q: Can I claim for the same service from both Medicare and my extras cover?
A: No, you can’t claim for the same service from both Medicare and your extras cover. Extras cover is designed to cover services that Medicare doesn’t. If Medicare covers a portion of the cost, your extras cover may then contribute to the remaining gap (but this is rare – most extras benefits are for services that are entirely outside of Medicare).
Q: What is the best way to compare different extras policies?
A: Use online comparison tools, read reviews, and contact the health funds directly to ask questions. Consider your individual needs and priorities when comparing policies.
Q: Can I change my extras cover at any time?
A: You can typically change your extras cover at any time, but you may be subject to waiting periods for certain benefits if you upgrade to a more comprehensive policy.
References
- Private Health Insurance Ombudsman
- Australian Financial Complaints Authority
Don’t let your extras cover gather dust. Take control of your health insurance and unlock the benefits you’re entitled to. Review your policy today, compare your options, and start maximizing your extras cover for a healthier and wealthier future. Your wellbeing—and your wallet—will thank you for it.
