Last Updated on 12 February 2020

Orthodontics and Private Health Insurance

Orthodontia is a form of dentistry that focuses on studying and treating issues such as improper bites, tooth irregularities and uneven jaw relationships. Both dentists and orthodontists are concerned with your oral health. So, what do they do differently?

Dentists and orthodontists undergo different types of training, and therefore, offer different kinds of services.

When you visit the dentist, you will most likely be checking up on the health of your teeth/gums, and in some cases, undergoing dental work or cleaning to improve your oral health.

Orthodontists are dentists who have undertaken further specialist training in orthodontics. They don’t perform routine dentistry. When you visit the orthodontist, you will be checking up on the physical structure of your jaw and bite to study irregularities that could be problematic (both now and in the future).

Orthodontic treatment is not covered under Medicare. This means you’ll have to pay for orthodontic treatment costs out of your pocket, or purchase private health insurance with orthodontic cover.

Key Points
  • Orthodontic treatments will vary patient-to-patient, and your age may determine which treatment plan is best for you. Treatment is less complicated while you are young as your jaw is still growing. As you enter adulthood, your jaw will ‘fix’ into a fully-grown position.
  • If you’re after coverage for orthodontics, you must select a policy that covers orthodontic services. Most policies that cover major dental services will also cover orthodontics – but not all.
  • Upon purchasing a new policy, you will generally need to wait 12 months before making an orthodontic claim.

What is orthodontics

Orthodontists are concerned with:

  • Diagnosing and treating malocclusions such as overbites, underbites, cross-bites, reverse bites and tooth crowding/crooked teeth
  • Treating misaligned jaw & tooth irregularities
  • Impacted teeth (teeth that did not erupt from underneath the gum)
  • Gaps and spaces between the teeth

Straightening teeth, or fixing a misaligned bite not only boosts your confidence, but improves your oral health, too. For example, it makes cleaning your teeth easier, and can prevent plaque build-up in areas where teeth are covered due to crowding.

What orthodontic treatments fix the issues noted above?

  • Braces (clear, ceramic and metal)
  • Lingual braces (braces behind the teeth)
  • Invisalign (clear aligners that look similar to retainers)
  • Palate expander (plate on the upper jaw)
  • Lip and cheek bumpers (wire, usually wrapped in plastic)
  • Headgear

Note that some of these treatments may go hand in hand. For example, a patient may require a palate expander followed by braces. Depending on your case, it may also be possible to have both of these appliances at the same time.

Your orthodontist will be able to talk you through the options. Ask questions or get a second opinion if you are unsure or uncomfortable about a part of the process or treatment plan.

See below for a quick explanation of each appliance listed above.

Types of orthodontic treatment explained

Orthodontic treatment for kids

It’s not uncommon for a child to require orthodontic treatment. Jaw misalignment and/or crowding of teeth can occur for a number of reasons. These reasons include:

  • A difference in size between the upper and lower jaws (causing a misaligned bite)
  • Tooth size (for example, bigger teeth in a smaller mouth can cause overcrowding or overbite)
  • Birth defects such as cleft lip and palate (less common)

Often, it’s recommended to get your child’s teeth checked by an orthodontist while they are young, because their jaws have not yet set in their permanent adult position. Because of this, it may be possible to expand/move the jaws.

Treatment may get more complicated once the jaws become fixed in adulthood.

Orthodontic treatment for adults

Orthodontic treatment for adults is a little more complicated, as the option to widen your jaw may no longer be available. Once the jaw is fixed in place, it becomes more difficult to shift the teeth. However, there are ways around this. Treatments for malocclusions include:

  • Traditional braces
  • Lingual braces
  • Invisalign (clear aligners)

One of the above treatments may also involve extractions. This is because the process of moving teeth into new, corrected positions requires both space and pressure. Your braces or clear aligners will shift your teeth, but they can only do this when there is adequate space for your teeth to move into.

If you have a smaller mouth/jaw with no gaps between your teeth, you may require tooth extraction. It’s best to speak to an orthodontist about which treatment plans are available for your individual case. What works for one patient will not be viable for another.

In saying this, if you are uncomfortable or unsure about your treatment plan, you should ask questions, enquire about alternative options and make sure you understand what your specific treatment plan involves from start to finish.

Private Health Insurance and Orthodontics

If you’re looking to purchase private health insurance to cover orthodontic treatment, you will need to select a policy that covers orthodontic treatment. Most policies that cover major dental services will also cover orthodontics – but not all.

What’s the difference between general and major dental? General dental covers things like teeth cleaning, small fillings and dental x-rays. Major dental covers more advanced procedures including crowns, bridges, dentures, and, in most cases, orthodontic care.

When comparing policies in regards to dental cover, consider the following:

  • What types of orthodontic treatments are covered.
  • Who can provide treatment. Most health funds pay less for orthodontic treatment provided by a dentist than for an orthodontist (an orthodontic specialist).
  • What the lifetime limit is on orthodontic benefits. Once the limit is reached, benefits no longer re-accrue and you may not claim any further orthodontic benefits over your lifetime.
  • What the waiting period looks like. Most health funds impose a 12-month waiting period.
  • How quickly benefits accrue. Some policies have starting limits of cover, which increase each year after the initial 12 month waiting period. Annual benefits increase until the maximum benefit is reached. Other policies pay a fixed benefit per year.

Policy limits and waiting periods

The standard waiting period for orthodontic cover is twelve months. This means that if you require any major dental work or orthodontic treatments before the twelve months is up, you will need to pay for these expenses out of your own pocket.

Once this waiting period is over, the amount of cover you receive is determined based on whether you have an accrued benefit policy or a fixed benefit policy.

So, what’s the difference?

Difference between an accrued benefits policy and fixed benefits policy

The chart below shows you an example of an accrued benefit policy. Note the difference in yearly benefits increases each year until reaching the capped limit of $1100 per year.

Coverage for Orthodontic Treatment

Example of an accrued benefits policy

Number of Years

Will my health insurance cover orthodontics?

As mentioned, many health funds offer extras policies that cover at least the partial cost of braces and other orthodontic treatments. Orthodontics cover can assist with the cost of orthodontic examinations, retainers and adjustments or other related appointments you or a family member may need.

But the level of coverage you receive will depend on your individual policy and circumstances.

If having the cost of orthodontics covered is important to you, you don’t want to go without health insurance. Consider when you will need the cover, as most orthodontics and dental services have a 12-month waiting period before you can claim.

If you’re concerned about waiting periods, your best bet is to double check the details of your policy with your insurer or a qualified health insurance adviser. If you’ve already booked an orthodontic consultation and know what treatments are being recommended, you will have a clearer idea of what to look for in terms of coverage. There is no need to obtain a referral in advance. Simply wanting to improve your smile is considered reason enough to book an appointment with an orthodontic expert.

You can request a quote for any recommended treatments cost, and keep this number in mind when you talk to your insurer or Health Insurance Comparison adviser.

You should always ask about the percentage the policy covers and the maximum amount claimable for course of treatment and per lifetime. This will give you a clearer idea of exactly how much your health fund will cover in the event you or a family member require orthodontic treatment.

If any of this sounds overwhelming, a good idea is to speak to an adviser over the phone where they’ll be able to explain the policy’s terms and conditions clearly and answer any additional questions you may have. They’ll also be able to compare policies for you to ensure you’re adequately covered for orthodontics on a competitively-priced policy.

All health funds will have a product disclosure document for each of their policies, which should also feature this information.

Do health funds cover braces?

Many health funds will cover costs associated with braces. However, there may be a coverage ceiling and lifetime limit, which could limit the amount your insurer pays out over the course of orthodontic treatment.

Nevertheless many Australians take out a comprehensive private health insurance policy that will take care of their dental and orthodontics needs, plus provide peace of mind for many other health events they may encounter.

How much do braces cost with health insurance?

Without private health insurance, it’s widely estimated that braces can cost anywhere from $3,000 to $10,000.

How much you need to pay often depends on what sort of orthodontic treatment you’re looking at and who you’re being treated by.

Traditional metal braces tend to lie at the cheaper end of the scale, while modern ceramic/lingual braces and Invisalign will often carry a higher price tag. Don’t forget about the cost of X-rays, extractions, plates, retainers and other orthodontic devices that you may need in addition to braces.

The good news is that health insurance can pay a portion of this amount for you. How much this lowers the cost of braces will depend on your policy, your orthodontic needs and your insurer, so it’s impossible to quote just one figure that will be relevant to everyone.

It’s also important to remember that the cost of getting braces involves more than just the braces themselves. Everyone is different, and unforeseen orthodontic problems may arise during or after treatment.

Orthodontic problems can be complicated and often necessitate the use of expensive equipment and facilities. X-rays, check ups, imaging services and adjustments will all add up. If your health fund is providing coverage for your orthodontia, then your policy may also pay a nice chunk of these costs for you as well.

Some people need to wear braces for years, and throughout this time require constant adjustments, such as having their braces tightened. A comprehensive health insurance policy with orthodontic benefits could help to ease the burden of these repeated costs significantly.

Are no gap policies available?

Unfortunately health funds do not provide ‘no gap’ policies for orthodontic treatment. Generous benefits are available in some instances but there will always be out-of-pocket costs to pay.

Some funds do, however, provide no gap policies for preventative dental care, which includes treatments and services such as check-ups, cleaning and scaling, fluoride treatments and x-rays.

Orthodontic needs can be complex, and every mouth is different.

If you know that your mouth needs work, or you’re in a family with young children who may potentially need work in the future, it could be worth considering private health insurance that covers orthodontics.

But don’t delay—leaving private health cover for orthodontics to the last minute can be an issue in some cases. For example, most orthodontic coverage will not cover braces if they have already been applied to the teeth prior to the day the policy begins. It then becomes an out-of-pocket expense.

If you’re in doubt, your insurer or a Health Insurance Comparison adviser will be more than willing to discuss with you how and when orthodontics services are covered by private health insurance.


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