Private health insurance and your dental treatment

Victorian Dental Group has HICAPS on site. Present your private health insurance card at reception and your rebate is claimed immediately — you pay only the gap.

The gap is the difference between our fee for the treatment and the amount your fund contributes towards it.

HICAPS works with most major Australian health funds. If your fund participates and your policy covers the item, the claim takes seconds and there is nothing to post, upload or chase afterwards.

The words, in plain terms

Health fund language is its own dialect, and most confusion about rebates comes from it.

Term What it means
Extras (or ancillary) The part of a policy that covers dental. Separate from hospital cover
Item number The ADA code for a specific procedure. The only precise way to ask your fund about a rebate
Rebate / benefit What your fund pays towards an item
Gap Our fee minus the rebate — the part you pay
Annual limit The most the fund will pay per person per calendar year
Sub-limit A separate cap on one category, such as major dental or orthodontics
Waiting period Time you must hold the policy before an item can be claimed
Benefit percentage The share of the fee the fund pays, up to its limits
Preferred provider A commercial fee arrangement between a fund and a practice
"No gap" The fund's rebate covers the whole fee for that item — usually only on routine preventive care

Quoting your cover before you commit

We can check what your fund will rebate for a specific treatment before you go ahead with it. The process is quick and only needs your health insurance card.

This is worth doing whenever a treatment is larger than a routine check-up. It turns "I think it is mostly covered" into an actual figure, and it is far better to know before the appointment than after it.

Do not have your card with you? Not a problem. Pay the account in full on the day and we will give you an itemised statement listing each item and its ADA item number. You claim directly with your fund afterwards and are reimbursed as usual.

Understanding what your policy actually covers

Dental sits under extras (or ancillary) cover, not hospital cover, and the terms vary enormously between funds and between policies within the same fund. A few things are true of most of them:

Feature What it usually means
Annual limit A capped dollar amount per person per calendar year. Unused amounts generally do not roll over
Per-item limits Some policies cap individual items as well as the annual total
Waiting periods Typically shorter for general dental, considerably longer for major dental. They restart if you switch to a higher tier
General dental Examinations, cleans, fluoride, fillings, simple extractions. Often rebated at a higher percentage
Major dental Crowns, bridges, dentures, root canal treatment, implants. Lower percentage, longer waits
Orthodontics Frequently a separate limit, often with a lifetime cap and a long waiting period
Cosmetic Whitening and veneers are commonly excluded entirely

The questions actually worth asking your fund

Ringing your fund and asking "am I covered for a crown?" rarely produces a useful answer. Ask instead:

  1. "What is my rebate for item number [X]?" — we give you the exact item numbers on your treatment plan, and this is the question the call centre can answer precisely
  2. "How much of my annual limit have I used this year, and when does it reset?"
  3. "Have I served the waiting period for this item?"
  4. "Is there a separate per-item or lifetime limit on it?"
  5. "Does my rebate change depending on which practice I attend?"

Write the answers down, with the date and the name of the person you spoke to.

Preferred provider arrangements

Some funds pay a higher rebate at practices they have a commercial arrangement with. It is worth understanding what that does and does not tell you.

What it means: the fund and the practice have agreed fee arrangements, so your out-of-pocket cost at that practice may be lower.

What it does not mean: that the practice is clinically better, more experienced or more highly regarded. It is a commercial arrangement between a practice and an insurer, not a quality rating, and it is not assessed by any regulator.

Ask us whether we have an arrangement with your fund, and ask your fund the same question. Then weigh the difference in gap against everything else you are considering.

Timing treatment around your limits

This is the single most useful piece of practical advice on this page.

Most extras policies reset on 1 January. Where treatment is not urgent and runs to a larger figure, splitting it across two calendar years means two annual limits apply rather than one. On a plan involving several crowns, or a crown plus an implant, that difference can be substantial.

We will tell you when a plan is worth sequencing that way. We will also tell you when it is not — delaying treatment on something actively deteriorating to chase a rebate is a false economy, and we would rather say so.

If you have limit remaining and have not had a check-up this year, that is also worth knowing in November.

A calendar worth keeping

When Worth doing
January Confirm your new limits and any policy changes. Book the year's first check-up
Mid-year Second preventive visit, if your policy covers two
October–November Ask what limit you have left. This is when a planned item is best scheduled
December Anything you have limit for and have been putting off — book early, it is the busiest month
Any time Urgent treatment. Never delay it for a calendar

If you are switching funds

Under Australian rules, when you switch to an equivalent level of cover, waiting periods you have already served generally carry over. Waiting periods do restart on any part of the cover that is new or higher, which is where people get caught — upgrading to get major dental means serving that waiting period from the upgrade date.

If you are switching specifically to get a treatment covered, ask the new fund in writing what waiting period applies to that item before you move.

Comparing policies

We do not recommend funds or policies. The government's own comparison service, privatehealth.gov.au, is independent of the industry and of us, and is the sensible starting point.

Two things worth noting when you compare. Hospital cover and extras are different products — dental treatment carried out in hospital under a general anaesthetic engages the hospital side of a policy, not extras. And a higher premium is only worth paying if you will actually use the limit; for many people, the annual limit on a mid-tier extras policy is not much more than the premium.

If a claim is rejected

It happens, and it is usually one of a handful of reasons: the waiting period has not been served, the annual or sub-limit is exhausted, the item is excluded, or the policy details on file are out of date.

Ask the fund which reason applies and under which clause. If you disagree with the answer, funds must have an internal complaints process, and beyond that, complaints about private health insurance can be made free of charge to the Commonwealth Ombudsman (ombudsman.gov.au), which handles private health insurance complaints.

We can reissue an itemised statement at any time if you need to re-lodge a claim.

What we can and cannot tell you

We can tell you what treatment you need, what each item costs, the ADA item number for each, what is urgent and what can wait, and — by running a quote through HICAPS — what your fund will rebate for a specific item today.

We cannot advise you on which fund or policy to buy, whether to upgrade, or whether insurance is worth it for your circumstances. That is financial advice, and a dental practice is not the right source of it.

What we would say generally: rebates are set by your fund, not by us, and our fee for a given treatment is the same regardless of who you are insured with.

We also will not plan treatment around what your policy happens to cover. The clinical recommendation comes first; the cover affects what you pay, not what you need.

If you do not have cover

You are not at a disadvantage in how you are treated here, and the same written quote process applies. Your options are the same ones on the payment options page — paying on the day, Afterpay, Zip, or staging the treatment over time by clinical priority.

Eligible children may be covered under the Child Dental Benefits Schedule regardless of private cover — see Medicare child dental benefits. Eligible concession card holders can access the Victorian public dental system, which is separate from this practice.

Questions we are asked

Will you charge more because I am insured? No. Our fees are the same whether you are insured or not.

Why was my rebate lower than last time? Usually because your annual limit is partly used, or because the item falls under a different category from the one you are thinking of. Your fund can tell you which.

Can I claim for a treatment plan in advance? Funds pay on treatment provided, not on plans. You can, however, get a quote of the expected rebate beforehand, which is what the HICAPS quote does.

Is whitening covered? Almost never. Purely cosmetic items are commonly excluded from extras cover.

My fund says I need a "pre-approval" — what is that? Some funds ask for a written quote and sometimes radiographs before major items. We can provide both; ask reception and allow a little time before you want the treatment done.

Can I use my partner's cover? Only if you are listed on the policy. Check with the fund.

Does Medicare cover any of this? Not for adults, other than in limited circumstances outside general dental practice. Eligible children aged 0–17 may be covered under the CDBS.

Can I claim for two cleans in a year? Most extras policies cover two preventive visits a year. Confirm yours, because the number and the interval vary.

Does my rebate change if I see an oral health therapist rather than a dentist? Rebates are paid on the item number, not the practitioner's registration category. Your fund can confirm for a specific item.

I have cover but never use it — should I keep it? That is a question for you, and possibly a financial adviser. What we can say is that funds pay preventive dental generously, so an unused policy and an overdue check-up is the worst combination.

Book an appointment

Victorian Dental Group — 291 Wattletree Road, Malvern East VIC 3145

Phone (03) 9088 5808 · Monday to Friday, 8:00am–5:00pm · closed weekends and public holidays

Book online at any hour, or read more about payment options and check-up and hygiene fees.

This page is general information about how health fund claiming works at this practice. It is not financial advice and does not take your circumstances into account. Rebates, limits, waiting periods and eligibility are set by your fund and should be confirmed with them. This page does not replace advice from a registered dental practitioner about your own circumstances. Please see our Disclaimer.

Can I claim my health fund at the appointment?

Yes. HICAPS terminals are on site, so bring your health fund card and the claim is processed there and then — you pay only the gap, which is the difference between the fee and what your fund contributes. All the major funds are supported. If you forget your card you pay in full and claim the rebate yourself afterwards.

How much will my fund pay?

That is set by your fund, not by the practice. It depends on your level of extras cover, the specific item numbers used, how much of your annual limit remains, and whether any waiting period still applies. Two people having identical treatment on the same day can receive quite different rebates. For certainty, ask for the item numbers in advance and quote them to your fund.

What are annual limits, and when do they reset?

Extras policies cap how much they will pay each year, usually with separate caps for general dental and major dental, and sometimes a sub-limit for individual items. These limits almost always reset on 1 January and do not carry over — anything unused is lost. If you have limit remaining late in the year and treatment is due anyway, it is worth asking whether it can be completed before the reset, and if treatment spans the new year, whether staging it across two limit periods helps.

What are waiting periods?

The time you must hold a policy before you can claim. General dental typically has a short waiting period of a couple of months; major items such as crowns, bridges, dentures and implants commonly carry twelve months. Waiting periods usually restart if you upgrade to a higher level of cover, and may restart if you switch funds, though funds often recognise periods already served on an equivalent level. Check with your fund before booking major treatment.

What is usually covered?

General dental — examinations, cleaning, X-rays, fluoride, fillings and simple extractions — is covered by most extras policies. Major dental — crowns, bridges, dentures, implants, root canal treatment and surgical extractions — is covered only on higher levels of cover, with longer waits and lower proportional rebates. Cosmetic treatment such as whitening and veneers is often excluded entirely. Orthodontics usually has its own separate limit and a lifetime cap.

What is a preferred provider?

An arrangement where a fund pays a higher rebate at practices it has contracted with, sometimes with no gap on a check-up and clean. It affects the size of your rebate, not the standard of care, and the treatment you need should not change because of it. Ask the practice which funds it holds arrangements with and ask your fund what difference it makes to your rebate.

Is extras cover worth having?

It depends entirely on how much dental care you and your family actually use, the premium, the limits and the waiting periods — for some people the rebates exceed the premiums and for others they do not. We are not able to advise on which policy to hold. The independent government comparison site privatehealth.gov.au lets you compare policies, and your fund can tell you what you have claimed against your limits this year.

Who can help me work out my rebate?

Your fund is the authority on your cover; the practice can give you the item numbers and fees to quote to them. Victorian Dental Group, 291 Wattletree Road, Malvern East VIC 3145 — phone (03) 9088 5808 or email info@victoriandentalgroup.com.au, Monday to Friday 8:00am to 5:00pm. You receive a written plan with costs before treatment starts.

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