Rebates and gap payments- ADA

• June 29, 2017
• Dr. Catherine-Anne Walsh

When you first take out private health insurance, the expectation is that you will receive rebates that cover a sizeable proportion of your expenses. But the reality is that rebates for dental services, which fall under what’s known as “extras” cover, rarely cover anything like the full cost of treatment. Despite claims of ‘no gaps’, many funds only cover on average about half the cost, leaving you to cover the gap that remains. This is most evident in your annual cap limits which are quickly exhausted and don’t come close to covering the full amount you’ve spent on dental treatment.

The gap between what you pay for treatment and what you receive back from your fund is largely influenced by the rebate percentage set by the funds. Yes, dental fees are a factor but only in so far as fees vary between dental specialists, meaning that the set percentage you receive back will also naturally differ. Also, it matters whether your dentist works in an independent practice, as the majority do, or whether they are in a contractual relationship with your insurer.

By and large, your dentist has no control or visibility over the rebate amount you receive. So when your insurer tells you that you are getting back such-and-such an amount solely because of the fees charged by your dentist, you should treat this reasoning with the healthy degree of scepticism it deserves.

The rebate amount you receive from your insurer, which typically sits at around 30-40% of the full fee paid, is representative of a wider issue in dental funding (demonstrated by this graph), where much of the burden for dental care falls on the individual, with insurers failing to shoulder their fair amount of the cost.

If you feel like you are being short-changed in some way by your private health insurer then you should check out other funds as well as making a complaint via the ADA’s Time2Switch campaign to the Private Health Insurance Ombudsman.