Orthodontic Treatment

Introduction

Orthodontics is the branch of dentistry which specialises in the diagnosis, prevention and treatment of problems in the alignment of teeth and jaws.

Orthodontic treatment generally involves the design and use of corrective appliances such as braces, removable appliances and functional appliances to bring the teeth and jaws into proper alignment.

Any dentist may carry out orthodontic treatment, but the vast majority of cases are managed by specialist dentists known as “Orthodontists” who have restricted their practice exclusively to orthodontic treatment.

The most commonly claimed orthodontic treatments are braces and removable appliances such as retainers which are used for the treatment of irregularities of teeth and jaws.    

What should I do if I need to claim orthodontic treatment? 

In some cases, health funds may need an Orthodontic Treatment Plan to determine your orthodontic benefits. Before under go any treatment, you should ask your orthodontist to provide you with a written Treatment Plan.

The Treatment Plan should include the estimated length of treatment time, the dental item number used to identify the treatment, the total cost of the orthodontics and how you intend on paying for the treatment i.e. upfront lump sum payment or monthly instalments over the duration of treatment.

Once you have your Treatment Plan, you should provide a copy to your health fund who can then give you a benefit quote based on your treatment and level of cover. 

How do orthodontic limits and waiting periods apply to my policy?

It is important to be aware that orthodontic benefits and limits do vary from fund to fund and generally you will need to serve a 12 month waiting period before you will be eligible to claim a benefit.

There are a number of health funds that increase your orthodontic benefits the longer you remain a member of the fund. This means that your orthodontic benefits will accrue over time until you reach the maximum benefit limit.

The following is an example of an accrued benefit based on a policy with a starting limit of $500 which then increases by $200 every year after you have served the 12 month waiting period:

1st year- $500

2nd year- $700

3rd year- $900

4th year- $1100

Your annual benefit will continue to increase until you reach the maximum benefit that a health fund will pay towards orthodontic treatment.

Not all health funds have accrued benefits as there are some funds that pay a fixed benefit per year. For example, a health fund might pay a maximum benefit of $800 per year toward orthodontic treatment which may then be capped at a maximum of $2000 overall.  

What if my orthodontic treatment is provided by a general dentist?

In most cases, a health fund will provide the same amount of orthodontic benefit you are entitled to claim, regardless of whether an orthodontist or a general dentist provides the treatment.

However, in some instances, a health fund may pay a lower benefit for orthodontic treatment that is provided by general dentist. So in order to ensure your health fund provides you with accurate benefit information, it is important that you advise your fund of who will be providing the orthodontic treatment. 

What is a “Lifetime Limit”?

Almost all health funds place a “Lifetime Limit” on orthodontic benefits. This means that once you have claimed the maximum benefit, you will not be eligible to claim any further orthodontic benefits during your lifetime and your benefits will not re-accrue.

We strongly advise that you check with your health fund to find out how your orthodontic benefits apply and what the maximum benefit limit is that you can claim over the course of treatment. 

What happens to loyalty limits when I change health funds?

If you are with a health fund where you accrue your orthodontic benefits over a period of time, the accrued amount is not transferable. This means that if you cancel your membership and transfer to another health fund, your accrued orthodontic benefits will not transfer over to a new fund. This will result in you having to start with a base benefit with a new health fund.

If you are thinking about transferring to a new fund, you can ask your new fund if they will consider recognising your accrued orthodontic benefits from your previous fund. You should do this before you make the decision to change funds. The new fund may choose to recognise your accrued benefits, but is under no obligation to do so. 

More Information

To check your orthodontic benefit and limits, contact your health insurer. To obtain quotes for orthodontic treatment, contact your provider of orthodontic treatment such as your orthodontist or general dentist. 

For more information on private health insurance, contact our office:

Websites: www.phio.org.au and www.privatehealth.gov.au

Phone: 1300 737 299

Download the Orthodontic factsheet (PDF)