Compare optical health insurance

When it comes to hospital cover, the federal government’s PrivateHealth website says most tiers of cover should include the investigation and treatment of the eye and eye socket for conditions such as retinal detachment, tear duct conditions, eye infections and medically managed trauma to the eye.

Such treatments are included in silver, bronze and gold tiers of private health insurance hospital cover. They may be optional or restricted in the basic tier of cover.

One of the most common eye conditions is cataracts, a clouding in the lens of the eye which leads to blurred vision. The federal government’s Health Direct website says cataracts are one of the leading causes of blindness, but the condition can be treated and vision restored.

While treatment for cataracts is covered by Medicare in the public health system, there may be a lengthy wait for any treatment, so you may want to consider what options are available with private health insurance. There may be wait times too in the private system, especially if you’ve just taken out a new policy or upgraded your cover.

Treatment for surgery to remove a cataract and replace with an artificial lens is optional up to the silver tier in private health cover, but is part of the maximum gold tier. Check with any potential health fund provider to see what options may be available to you.

If you want to get optical health insurance for out-of-hospital services, some of the extras policies offered by private health insurance providers include this.

It’s where you’ll find options for cover that can help with the cost of prescription glasses and contact lenses, which are not covered by Medicare. The Department of Health and Aged Care says health insurance policies can offer different levels of extras cover and will only cover some of the costs for most services.

For example, they may offer a certain percentage or a certain amount towards the overall cost of any optical treatment. You may also be limited as to how much or how often you can claim each year.

Optometry Australia, the peak body for optometrists, said extras cover for optical may be worth considering if you need to upgrade your glasses or contact lenses on a regular basis.

Be mindful that not all optical services may be covered by an extras policy. For example, there may be no cover towards special lens coatings.

Unlike hospital cover, there is no defined tier listing for extras cover so it’s up to each fund to determine what will and will not be covered by any particular policy. For example, only some policies may provide cover for treatment of conditions such as crossed eyes or double vision.

You need to shop around and compare policies to see what may suit your particular needs.

Depending on what fees are charged by your practitioner, and what may be covered by Medicare and your private health insurance policy, you may still incur some out-of-pocket expenses.

Your private health fund and Medicare will generally share cover for the cost of treatment up to an amount determined by the Medicare Benefit Schedule (MBS). But there is no cap on what a practitioner may charge for treatment, so anything above that MBS limit you may have to fund yourself, often referred to as the gap.

Dr Peter Sumich, President of the Australian Society of Ophthalmologists (ASO), told Canstar that practitioners try to do what they can to keep costs down but “gaps will always be there”.

Generally though, he said the cost for most eye surgery was relatively low compared to procedures such as joint replacement. There may also be some provisions available for patients in hardship but those would be considered on a case by case basis.

The ASO says you also need to be aware that private health funds are only permitted to fund services in a hospital or day surgery, not in a doctor’s rooms, so you may not be covered for some treatments.

When discussing treatment with an ophthalmologist, you should be given the details of any costs involved up-front, usually in a printed document known as Informed Financial Consent (IFC). There may be costs from other specialists in any treatment, such as an anaesthetist, so you should get a separate Informed Financial Consent from each one.

If it’s not clear what you may need to pay, you should ask for details.

The Australian Medical Association offers suggestions on what you should ask your practitioner about costs. They include:

1. What are your fees?
2. Are there any fees for other doctors?
3. Will I have any out-of-pocket costs?
4. Is your fee an estimate only?
5. Can I have an estimate of your fees in writing?
6. If the cost changes, when will you let me know?
7. What if I need a prosthesis/implant?

You should also contact your health fund to see what fees or other charges it will cover, and how much it will pay out? Not all medical services are listed in the MBS.

The government’s PrivateHealth website says some private health funds have agreements with particular doctors or health care providers that may help cover some or all of any gap fees for your in-patient hospital treatment. Again, you might be wise to check with your fund and practitioner to see if such an agreement exists before committing to a treatment.

Private Healthcare Australia is the peak body for the industry and CEO Dr Rachel David told Canstar it’s important that you review your health insurance policy from time to time to make sure you have appropriate cover.

“As you get older, you might need treatment you haven’t considered in the past, such as cataract surgery,” she said. “Your needs change as your life stage changes.”

Medicare will cover all or part of the cost of most surgery and procedures performed by doctors in the public health system, including the treatment of certain eye conditions. The Medicare Benefits Schedule (MBS) lists the Medicare services subsidised by the Australian Government.

“As a general principle, any procedure performed in a private hospital can also be performed in a public hospital,” a Department of Health spokesperson told Canstar.

The difference without private health insurance, though, is that you won’t get to choose your surgeon and you could face a lengthy wait for treatment in the public health system, depending on the severity of your condition.

Medicare will cover the cost of an eye test if you choose an optometrist that bulk bills.

If you’re aged under 65, you can get one bulk billed eye test every three years. If you’re 65 or over you can get a bulk billed test yearly. You would be wise to check though as not all optometrists bulk bill.

But remember, Medicare won’t cover the costs of any prescription glasses or contact lenses you may need, and it doesn’t cover the costs of laser eye surgery unless any treatment is considered medically necessary.

When you sign up for a new private health insurance policy, or increase your level of cover, you may be required to wait a certain period of time before you can claim for certain treatments.

The PrivateHealth website says for hospital cover you may be required to wait up to two months for treatment of any new condition, or wait 12 months for a pre-existing condition. Pre-existing is defined as something you had signs or symptoms of during the six months before you joined a hospital cover or upgraded your policy.

When it comes to extras cover, waiting periods can vary from two to six months for items such as general optical treatment.

Some private health fund providers may waive those extras waiting periods as part of a promotion to get you to sign up for a new policy.

You can compare a wide range of private health insurance policies that include optical cover by using the comparison tool at the top of this page. You can tailor the results by changing the filters to suit your requirements. When comparing policies, it’s important to look at a range of factors, such as:

• What is covered and what’s excluded?
• How much will the premiums cost?
• What excess will I need to pay if I make a claim?
• Whether you need cover for pregnancy and birth
• What hospital inclusions do you need?
• What cover do you need for your age and time of life?

It’s a good idea to carefully read the  policy documents to see what level of treatment is covered, what’s excluded and what limits apply, to ensure that a product you’re considering is right for you.