Extras cover explained: annual limits, benefit percentages and what Medicare skips
How extras (general treatment) cover pays for dental, optical, physio and other services, how limits and combined limits work, and how it fits with Medicare and the rebate.
Extras cover, also called general treatment or ancillary cover, pays a benefit towards health services you receive outside hospital that Medicare generally does not pay for: dental, optical, physiotherapy, chiropractic, podiatry, psychology, dietetics and similar. It never pays the whole bill unless the policy says "no gap" for a specific service. Each service type has an annual limit, many policies combine limits across services, and each insurer sets its own waiting periods. Extras cover is eligible for the government rebate but does not avoid the Medicare Levy Surcharge or the Lifetime Health Cover loading.
This guide is part of private health insurance and Medicare explained.
How a benefit is calculated
Insurers use one of three common methods. The figures below are illustrative.
| Method | How it works | Example on a $90 physio visit |
|---|---|---|
| Fixed dollar benefit | A set amount per item number | $45 back, you pay $45 |
| Percentage of the fee | A share of the charge, up to a cap | 60% = $54 back, you pay $36 |
| No gap at a network provider | Full fee paid for set services with participating providers | $0 out of pocket for a check-up and clean |
Dental benefits are tied to Australian Dental Association item numbers, so ask your dentist for the item numbers and your insurer for the benefit on each before treatment.
Annual limits
- Per-service limits: for example $600 for general dental, $250 for optical.
- Combined limits: for example $900 shared across physio, chiro and osteopathy.
- Lifetime limits: common for orthodontics.
- Limit periods: most reset on 1 January or 1 July, depending on the insurer. Unused limits do not roll over unless the policy offers a loyalty increase.
Example (illustrative). A policy has a $750 general dental limit and pays 60% of the fee. Two check-ups at $230 each, including scale, clean and X-rays, return 60% × $460 = $276. A filling at $260 returns $156. Total benefit $432, within the $750 limit. You paid $950 in fees and got $432 back, so your out-of-pocket is $518.
What Medicare covers outside hospital
Before buying extras, check whether a public program already helps:
- Child Dental Benefits Schedule: a Medicare-funded benefit for basic dental services for eligible children aged 0–17, usually in families receiving certain government payments.
- State public dental services: free or low-cost dental care for eligible concession card holders, often with waiting lists.
- Chronic condition management plans from a GP can attract Medicare benefits for a limited number of allied health visits a year.
- Mental health treatment plans allow Medicare-rebated psychology sessions.
- Eye examinations by optometrists are generally Medicare-rebated; glasses and contact lenses are not.
Insurers cannot pay an extras benefit on top of a Medicare benefit for the same service, so a psychology session claimed under Medicare is not also claimable on extras.
Waiting periods
Insurers set extras waiting periods. Common patterns are 2 months for general dental and physio, 6 months for optical, and 12 months for major dental, orthodontics and hearing aids. Some insurers waive short waits as a promotion; that is a marketing feature, not a rule. See waiting periods.
The rebate and extras
The rebate applies to extras premiums at the same percentage as hospital cover. At the base tier for under-65s, a $900 extras premium costs $900 × (1 − 0.24118) = $682.94 after the rebate.
Is it worth it?
Extras cover is a budgeting product more than insurance against large costs. It tends to be good value if you reliably use services near the limits every year, and poor value if you claim little. The extras worth-it calculation shows how to test it with your own usage.
Extras on family policies
On a family policy, limits can be per person or shared across the policy, and the difference matters. A $600 per-person dental limit for four people allows up to $2,400 in dental benefits a year; a $1,200 shared family limit allows half that. Children's check-ups are often paid at higher benefits or with no gap at network dentists. Orthodontic benefits usually come with a lifetime limit per person and a 12-month waiting period, so a policy taken out when braces are first mentioned may not pay in time. If your children are approaching the age when orthodontics is common, ask the dentist about timing and check waiting periods early.
Questions to ask before buying
- Which services do I use each year, and what do they cost?
- Is the benefit a fixed amount or a percentage, and is there a per-visit cap?
- Are limits per person or shared across the policy?
- Do I have to use a network provider to get the best benefit?
- When do limits reset, and what waiting periods apply?
- Can I buy extras separately from hospital cover, possibly from a different insurer?
FAQ
Can I have extras with one insurer and hospital with another?
Yes. Many insurers sell extras-only policies. Splitting them can cost more in premiums or less, so compare the total.
Do extras benefits count as income?
No. Benefits are reimbursements, not income.
Are cosmetic dental treatments covered?
Policies define covered item numbers. Whitening and other cosmetic procedures are often excluded. Ask the insurer with the item numbers from your dentist.
If I upgrade my extras, do I start new waiting periods?
Usually yes, for the higher benefits. Your existing level continues to apply in the meantime.
Sources
- PrivateHealth.gov.au — general treatment cover and policy statements
- Services Australia — Child Dental Benefits Schedule and Medicare benefits
- Australian Dental Association — dental item numbers and patient information
- Department of Health, Disability and Ageing — Medicare-funded allied health and mental health plans
