Orthodontic Benefit Entitlements
Waiting periods
Orthodontic treatment is considered as major dental. There is a 12 month waiting period that applies for major dental services. Waiting periods will apply to:
- New memberships (previously uninsured).
- Additions to 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.
- Existing GMHBA memberships, and transfers to GMHBA from another fund where the level of cover and/or benefit entitlement is upgraded or increase and/or where the waiting periods have not been completed.
| Product | Benefits | Calendar year limit per person. Based on years of members at current product level | Lifetime limit per person |
|---|---|---|---|
| Top Extras 75% | 75% of cost up to annual limit |
Years 1-3: Up to $700 per cal year Year 4: Up to $800 per cal year Year 5: Up to $900 per cal year Year 6+: Up to $1000 per cal year |
$3,200 |
| Top Extras Set Benefits | 85% of cost up to annual limit | ||
| Mid Extras 65% | 65% of cost up to annual limit |
Years 1-3: Up to $400 per cal year Year 4: Up to $500 per cal year Year 5: Up to $600 per cal year Year 6+: Up to $700 per cal year |
$2,400 |
| Mid Extras Set Benefits | 75% of cost up to annual limit | ||
| Silver Package with AIA Vitality | 60% of cost up to annual limit |
$500 per person per cal year |
$1,800 |
| Premium Extras | 100% of cost up to annual limit |
$800 per person per cal year |
$2,800 |
How benefits are calculated
Your benefit entitlements are calculated based on the amount of completed membership years you have had on your current level of extras cover at the time the treatment commences.
For example, if you upgrade your existing extras cover or join GMHBA from another fund onto Top Extras Set Benefits, your orthodontic benefits are calculated based on membership years 1-3 for Top Extras Set Benefits.
In addition, orthodontic benefits are stepped, and increase each year.
For example a member on Top Extras Set Benefits with 3 years of completed membership at the beginning of the treatment commencing will receive:
- 85% of the cost up to $700 in the first year of treatment (based on 3 years of completed membership)
- 85% of the cost up to $800 in the second year of treatment (based on 4 years of completed membership)
- 85% of the cost up to $900 in the third year of treatment (based on 5 years of completed membership)
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 major dental benefits
- You have served any waiting periods for these services
- There are benefits available to claim in your overall dental annual limit
Orthodontic annual limits are a sublimit of dental benefits on Top Extras 75%, Top Extras Set Benefits, Mid Extras 65% and Mid Extras Set Benefits. Any amounts claimable are deducted off your overall dental limit. Orthodontic annual limits on the Premium Family, Everyday Family and Starter Family Packages are standalone 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 Hicaps, you’re able to claim benefits on the spot using your membership card. In the instance that you’re unable to claim using your membership card, you can ask for an itemized account and claim in a branch or by mailing or emailing your claim to us on a claim form.
Please note that the benefits and rules as outlined above apply only to those products listed. If you are on any other extras product, please note that you will need to contact us for a benefit estimate at this time. You can contact our team on 1300 446 422 for a quotation.
Important
All extras services must be provided by practitioners in a private practice who are appropriately registered with the recognised bodies approved by GMHBA. We recommend you contact us for a benefit estimate before commencing treatment to confirm the benefit payable.
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 call 1300 446 422, visit your local branch or gmhba.com.au.