Understanding Your Dental Fee Gap and Health Fund Rebate

Have you ever looked at a treatment plan, then checked your health fund statement, and wondered why the numbers don’t seem to make sense? It happens more than you’d think! Working out what is covered and what you may need to pay yourself is not always straightforward.

The difference between the dental fee and the amount your health fund pays towards it is known as the “gap.” And how big that gap is can vary quite a bit from person to person and policy to policy with the same private health insurer.

Why the Same Treatment Can Come with a Different Rebate

Your rebate depends on several things: your private health fund, your level of cover, the treatment you’re having, any annual benefit limits, waiting periods or exclusions, and how much of your benefit you have already used.

Yes, it is possible to have two patients sit in the same chair, have the exact same treatment, and end up with different rebates.

Unfortunately we have no control over how much your health fund pays. What we can do is give you the treatment details and item numbers you need to request an estimate directly from your insurer before going ahead. We will always try our best to answer your questions, and provide a HICAPS gap-cost estimate based on general knowledge – but nothing beats going directly to the source and making direct enquiries with your private health insurer.

Questions Worth Asking Your Health Fund

Policies change and levels of cover change, and often this information is sent to patients in a generic looking email  with a new PDS (product disclosure statement). It’s worth checking in on yours from time to time to see whether it still suits your needs.

Before starting treatment, you may want to ask your health fund:

• Is this treatment included in my cover?
• How much can I claim for each item number?
• Do annual or lifetime limits apply?
• Have I served the relevant waiting periods?
• How much of my annual benefit is left?
• When do my benefits reset?

Ask for your policy’s Standard Information Statement too. It can make comparing your cover, and understanding what limits apply, a lot easier.

Getting More From Your Extras Cover

If you pay for extras cover, it’s worth understanding what is actually available to you and how those benefits fit with your dental needs.

Many health funds reset extras benefits annually, though the timing varies from fund to fund, and unused amounts may not roll over. If you are due for a checkup, professional clean or planned treatment, booking before your benefits reset (or “expire) may mean getting more value from premiums you have already paid.

There is another reason to keep up with regular dental visits: they may give your dentist the opportunity to pick up concerns earlier, when treatment can sometimes be simpler and more manageable.

What You Can Ask Us Before Treatment Begins

Before moving ahead with recommended treatment, ask us anything. What will it cost? What are the item numbers? What are the options? Can it be done in stages? Are there payment options available?

For more involved care, we can prepare a treatment plan so you can see exactly what has been recommended and discuss your expected rebate directly with your private health fund.

The right level of cover depends on your circumstances, your oral health needs and your budget. Reviewing your policy every so often helps you work out whether your current cover still offers good value.