A typical implant with its crown costs several thousand dollars, and a health fund rarely pays more than part of it. Extras cover with major dental can contribute once your waiting period has been served, but the benefit is limited by your policy's yearly limits and the rules your fund applies to each item. Medicare does not cover implants in almost all cases, so the gap is usually the larger share.
Written by Dr James Tran, BDent (University of Sydney), MICOI, GradDip (Oral Implants), general dentist at Lumi Dental in Melrose Park.
Implants are claimed under extras, usually as major dental
Dental treatment done in the chair is claimed under extras (general treatment) cover, not hospital cover. Extras policies usually divide dental into general dental, covering check-ups, cleans and X-rays, and major dental, covering larger work such as crowns, bridges and implants. Lower-level extras policies sometimes leave out major dental altogether, or list implants as an exclusion, so the first step is reading your policy information or asking the fund directly.
Even when implants are included, the benefit comes out of a yearly limit. Some funds also apply a separate limit for implants, a combined limit shared with other major items, or a lifetime limit. Our article on how dental extras limits reset explains how the timing works.
Rebates are set by the fund, not the dentist
The Australian Dental Association's consumer site notes that an average rebate is about 50% of the cost of dental treatment, that some not-for-profit or restricted funds may pay up to 75%, and that the rebate is set by the insurer rather than the practitioner. Funds may also pay a higher rebate at their preferred providers, although you can still choose any dentist. For a large item like an implant, the yearly limit often matters more than the percentage.
Waiting periods usually mean planning a year ahead
When you take out a new policy or upgrade, you must serve waiting periods before you can claim at the new level. The Commonwealth Ombudsman's factsheet on dental and oral surgery says major dental usually has a waiting period of 12 months or more. General dental waiting periods are shorter, commonly about two months, but each fund sets its own, so check yours. Taking out extras a few weeks before an implant will not help with that implant. If you are changing funds, ask the new fund in writing whether the waiting periods you have already served will be recognised. Our guide to dental waiting periods covers this in more detail.
Funds pay by item number, so get an itemised quote first
Health funds do not assess the word "implant". They pay a benefit for each three-digit dental item number on the claim. An implant plan normally includes several items across different stages, such as planning scans, placing the implant, connecting the abutment and fitting the crown, and possibly grafting. Each one may sit in a different category or draw on a different limit.
The Ombudsman recommends asking for a quote, preferably in writing, that lists the item numbers, the fees and the provider's name and provider number, then checking your benefits with your fund. Any difference between the benefit and the fee is yours to pay. When you call, it helps to ask:
- What is the benefit for each item number on this quote?
- Which limit does each item come from, and how much of that limit is left this year?
- Is there a separate or lifetime limit for implants?
- Have I served the waiting period for major dental?
- Is bone grafting covered, and under which category?
Write down the date and the name of the person you spoke to. If a claim is later refused, our article on why a health fund declines a dental claim covers the common reasons.
When hospital cover comes into it
Most single implants are placed in the dental chair under local anaesthetic, so hospital cover plays no part. It becomes relevant only if surgery is done in hospital, for example under general anaesthetic for extensive grafting. In that case, the Ombudsman explains that you need both hospital and extras cover for the maximum benefit: the dentist's or surgeon's items are claimed under extras, while hospital accommodation and theatre fees are covered by hospital cover if your policy includes the service and you are admitted to one of the fund's agreement hospitals. For the anaesthetist, Medicare generally pays 75% of the Medicare Schedule Fee and the fund pays the remaining 25%, and anything charged above that is a gap.
Not every hospital policy includes dental surgery, so confirm your cover and excess before any admission. Lumi Dental does not provide general anaesthetic; for in-chair treatment, ask us about sedation options. Our guide to hospital cover versus extras cover for dental treatment explains the difference further.
Plan for the gap
As a general guide, the typical Australian market range for a single implant with its crown is about $4,000 to $7,000, and cases needing grafting or extra procedures can cost more. This is a market range, not a Lumi fee. Compared with a major dental limit, the gap is often most of the cost.
A few things can help. Because each stage is claimed when it is done, the implant and the crown sometimes fall into different benefit years, which can let you draw on two years of limits; that depends on your treatment timeline and your fund's rules. A payment plan can spread the cost, and our article on dental payment plans covers what to check before signing. In limited circumstances, early release of superannuation may be approved for dental treatment, which our guide to early release of super explains.
How we prepare an implant quote at Lumi
An implant consult at Lumi Dental starts with an examination, a 3D X-ray and an intraoral scan taken at the practice, so the plan reflects your actual bone and gum. You will usually receive a written treatment plan, often by email, setting out each stage with its item number and fee so you can ask your fund for a benefit estimate before deciding. Health fund benefits can be claimed on the day through HICAPS. Complex grafting cases may be referred to a registered specialist. See current deals for consult offers, or read more about dental implants at Lumi Dental.
Common questions
How much will my fund pay towards an implant?
It depends entirely on your policy. The only reliable figure is the estimate your fund gives you against an itemised quote.
Does Medicare cover dental implants?
Almost never. The ADA notes that Medicare covers dental care only in certain situations, such as the Cleft Lip and Palate Scheme.
Is an implant general or major dental?
Major dental on most policies, with a longer waiting period and its own limit. Check your policy, because categories vary between funds.
Get a quote you can take to your fund
If you are missing a tooth and want to know what your fund might contribute, Lumi Dental in Melrose Park offers a free implant consult where the site is examined, a 3D X-ray is taken and an itemised plan is prepared. Contact us to book.
Sources
- Commonwealth Ombudsman: Dental and oral surgery factsheet
- Commonwealth Ombudsman: Waiting periods
- Australian Dental Association (teeth.org.au): Private health insurance
About the author
Dr James Tran is a general dentist at Lumi Dental in Melrose Park. He holds a BDent from the University of Sydney and a Graduate Diploma in Oral Implants, and is a Master of the International Congress of Oral Implantologists (MICOI).
This article is general information only and is not a substitute for an examination and individual advice from a registered dental practitioner. Suitability for any treatment varies from person to person.
