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Private Health Insurance and Orthodontics

Jonathan January 6th, 2015 0 comments

Orthodontia is a subset of general dentistry focused on studying and treating improper bites; tooth irregularities and disproportionate jaw relationships.  Orthodontics is not covered by Medicare in Australia. This means you need to either pay out of pocket for care or purchase private health insurance that covers orthodontics.

What is Orthodontics?

Orthodontists diagnose and treat malocclusions, such as overbites and underbites.  If teeth are irregular or the jaw is misaligned, an orthodontist provides corrective care.  Braces are the best known type of treatment an orthodontist provides.  However, other techniques may be used to move teeth including:

  • Headgear, which includes a metal wire in the front face and a strap around the back.
  • Aligners, which are an alternative to braces for adults.
  • Lip and cheek bumpers designed to relieve pressure on the teeth.
  • Retainers, which stop teeth from moving back after other appliances are used
  • Palate expanders, which make the upper jaw arch wider

An orthodontist will choose an appropriate treatment type after an exam and x-rays.

What Do Orthodontists Treat?

Orthodontics is intended to correct:

  • Protruding front teeth
  • Impacted teeth
  • Crowding of teeth
  • Teeth that are asymmetrical
  • Overbites, reverse bites open bites, cross bites and underbites
  • Gaps and spaces between the teeth

Orthodontic Treatment for Kids

The Australian Society of Orthodontists indicates that the majority of orthodontic problems are apparent by the time a child is seven years of age. Early treatment can prevent the development of more serious problems and can make treatment less complicated.

The fee for orthodontic treatment that includes both upper and lower braces typically varies from between $4500 to $8000 or higher.

Orthodontic Treatment for Adults

Orthodontic treatment can be successful for adults. However, because the facial bones stop growing once adulthood is reached, braces alone are often not sufficient to correct severe malocclusions (bite problems).[3]

Jaw surgeries in combination with braces and other orthodontic treatments can achieve results for most adult orthodontic problems. Costs for adult dental treatment can be higher than for children.

Options such as Invisalign braces are available for adults who wish to correct bite problems but who are embarrassed about visible braces.

What Types of Orthodontia Procedures are Covered by Medicare?

Medicare does not cover any type of dental care for adults in Australia. Children are eligible for up to $1,000 in dental services over two consecutive calendar years.  However, benefits are not available for orthodontia.   Purchasing private health insurance is required to obtain cover for orthodontia procedures.

Private Health Insurance and Orthodontia

The type(s) of orthodontic treatments covered by private insurance varies depending upon the policy. To obtain any type of cover, you will need a health insurance policy that covers major dental. A general dental policy provides payments only for things like teeth cleaning, small fillings and dental x-rays.  A major dental policy covers more advanced procedures including crowns, bridges, dentures, and orthodontic care.

Compare plans to determine:

  • 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 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 is. 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

Twelve months is the standard waiting period to become eligible for any type of orthodontics benefits for adults or children.  At the end of the waiting period, the amount of cover is determined based on whether you have an accrued benefit policy or a fixed benefit policy.

Accrued benefits policy base cover on the number of years you have had the plan. This chart shows how your cover limits for orthodontia may increase for each year you have your health plan after the waiting period. Cover will continue to increase until you have reached the maximum policy limits for orthodontics:


Accrual amounts are not transferrable. If you switch to a new fund, you generally cannot move your accrued benefits and will have to start over with a base benefit. You should ask your fund if they will recognize accrued benefits before making a switch, and take this into consideration when choosing new cover.

Are No Gap Policies Available?

No Gap dental service policies are available through private health insurers. These policies provide eligible preventative dental treatment without any out-of-pocket costs. However, no gap policies generally cover things like exams, cleaning and scaling, fluoride treatments, preventative exams and x-rays. Orthodontia is not covered.

Orthodontics plans will provide rebates for care based on treatment plans, up to policy limits. Any additional funds must be paid out of pocket.

Disclaimer: The above information is correct and current at the time of publication.

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