Orthodontic benefit entitlements
Orthodontics is a branch of dentistry concerned with the diagnosis, prevention and treatment of the misalignment of the teeth and jaws. Orthodontists use a range of techniques and treatment options to bring the teeth and jaw into alignment. These may include a course of corrective treatment using traditional braces, plates, fixed or removable retainers e.g. Invisalign.
Please contact GMHBA prior to undergoing any orthodontic treatment to confirm the benefits available.
Waiting periods
Orthodontic treatment – when included on your cover – has a 12-month waiting period.
Waiting periods for extras will apply to:
- New GMHBA memberships (previously uninsured).
- Existing GMHBA memberships, and transfers to GMHBA from another fund where the level of cover and/or benefit entitlement is upgraded or increased and/or where the waiting periods have not been completed.
- Additional members added onto a membership (unless the addition/s has already served all waiting periods with GMHBA or another fund) except newborns, adopted and permanent foster children where the family membership has been in existence for at least 2 months.
Find out more about waiting periods.
How are orthodontic benefits calculated?
Benefit entitlements for orthodontics are calculated in different ways, depending on the extras cover and whether this is an included service. Refer to your fact sheet for an outline of orthodontic benefits for your cover.
On ClassicCare Mid Extras 65 and Mid Extras Set Benefits, orthodontic benefits are based on a member’s tenure at the current product level and the sub-limit per person increases from years 3 to 6. Note that this is based on the completed membership years you have had on your Mid Extras cover at the time the treatment commences.
For example, if you upgrade your existing extras cover or join GMHBA from another fund onto Mid Extras Set Benefits, your orthodontic benefits are calculated based on membership years 1-3 for Mid Extras Set Benefits.
In addition, orthodontic benefits are stepped and increase each year. A member on Mid Extras Set Benefits with 3 years of completed membership at the beginning of the treatment commencing will receive:
- 75% of the cost up to $400 in the first year of treatment (based on 3 years of completed membership)
- 75% of the cost up to $500 in the second year of treatment (based on 4 years of completed membership)
- 75% of the cost up to $600 in the third year of treatment (based on 5 years of completed membership)
A lifetime limit of $2,400 applies per person for orthodontic treatment at this level of cover.
Orthodontics are included on all SmartCare Complete Extras and members are entitled to receive 60% back on claims for treatment up to their annual $1,500 Smart Limit or $750 sub-limit amount, depending on the cover, and once waiting periods have been served. A lifetime limit of $3,000 applies per person for orthodontic treatment at this level of cover.
| Product | Benefits | Annual limit | Lifetime limit per person |
|---|---|---|---|
| Mid Extras 65% | 65% of cost up to annual limit |
Orthodontic sub-limits per person (based on tenure at current product level) Years 1-3: $400 Combined annual limits for general dental, major dental and orthodontics |
$2,400 |
| Mid Extras Set Benefits | 75% of cost up to annual limit | ||
| SmartCare Complete Extras | 60% of cost up to annual limit |
$1,500 combined annual limit^ per person for all included services |
$3,000 |
| SmartCare Complete Extras with sub-limits | 60% of cost up to sub-limit or annual limit |
$750 sub-limit per person, per calendar year |
|
| SmartCare Complete Boost Extras | 60% of cost up to annual limit |
$1,500 combined annual limit^ per person for all included services, excluding optical |
|
| SmartCare Complete Boost Extras with sub-limits | 60% of cost up to sub-limit or annual limit |
$750 sub-limit per person, per calendar year |
^ $1,500 is the total Smart Limit for SmartCare Complete Extras and it is up to the individual if the entire Smart Limit amount is spent on orthodontics.
What are lifetime limits?
Lifetime limits are the maximum amount that can be claimed for a service over the lifetime of a policy.
A lifetime limit applies to orthodontic benefits, per person on the membership. Once you have claimed the maximum lifetime limit, you will not be eligible to claim any further orthodontic benefits during your lifetime, and your benefits won’t re-accrue or reset. This information is shared between health funds, and your lifetime limit will not reset if you transfer your policy.
Orthodontic claiming and rules
In order to claim orthodontic benefits, you’ll need to ensure that you:
- are on a level of extras cover that includes orthodontic benefits
- have served any waiting periods for these services
- have remaining benefits to claim in your overall annual limit, combined limit or sub-limit as well as your lifetime limit.
Visit the member area and check your fact sheet for an outline of orthodontic benefits payable for your cover including annual limits, combined limits or sub-limits (if applicable) and lifetime limits.
Your treating dentist or orthodontist should be able to provide you with a cost estimate of your treatment through an orthodontic treatment plan. This will help you calculate your out-of-pocket costs for orthodontic treatment.
If your dentist or orthodontist has electronic claiming facilities, you’re able to claim benefits on the spot using your GMHBA member card. In the instance that you’re unable to claim using your member card, you can ask for an itemised account and submit a claim via the GMHBA app, member area or at your local branch.
Please note that the benefits and rules as outlined above apply only to those products listed. If you are on an extras cover not shown here and would like a benefit estimate, please refer to your fact sheet or contact our team on 1300 446 422 for more information.
Important
All extras services must be provided by practitioners in a private practice who are registered with the recognised bodies approved by GMHBA. You can search for a registered orthodontist near you using the find a provider search tool.
Find out more
If you’re planning treatment, please call us to discuss your options to ensure you’re covered and have served all relevant waiting periods. For further information please contact our customer service team on 1300 446 422, via webchat or by visiting your local GMHBA branch.