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Health Insurance with Optical Cover

Key Points

  • Optical cover reduces out-of-pocket expenses for glasses and contact lenses.

  • Prescription sunglasses are covered, but non-prescription ones are not.

  • Annual limits dictate how much you can claim for optical services each year.

  • Out-of-pocket costs can be minimised by using preferred partners for higher rebates.

  • Most policies have a waiting period before you can claim optical benefits.

  • Health fund rebates for optical are applied automatically via HICAPS machines.

  • Assessing your optical needs helps in choosing the right policy.

  • Compare policies based on cost versus benefits for better value.

  • Utilise no-gap options to avoid additional out-of-pocket expenses.

  • Age-related conditions like cataracts require a higher level of hospital cover.

Eye care expenses can accumulate quickly, but having the right private health insurance with optical coverage can significantly reduce out-of-pocket costs. If you’re seeking financial relief for eye care, including routine prescription glasses and contact lenses, private health insurance with optical coverage might be exactly what you need.

All health funds in Australia offer optical coverage, providing you with various options to suit your needs. Choosing the right insurance plan can be time-consuming, but you can simplify the process with the Compare Your Health insurance comparison tool. This tool is designed to help you find the health fund policy that best fits your individual needs.

In this article, we’ll walk you through everything you need to know about health insurance with optical coverage. We’ll cover the associated costs, the type of coverage you can expect, the benefits of health insurance, and much more. Let’s dive in and get started!

Understanding Optical Cover in Health Insurance

What is Optical Health Insurance?

Optical health insurance is a type of private health insurance that specifically covers prescription glasses and contact lenses. Most health insurance providers offer optical coverage as part of their extras cover. If you wear prescription glasses or are considering contact lenses, having optical coverage can be extremely beneficial. This type of insurance helps cover the costs of glasses, frames, lenses, and even the repair of your glasses.

How Optical Cover Works

Optical cover functions in much the same way as any other health fund insurance policy. You begin by purchasing optical cover as part of your extras cover. Depending on your specific policy, there may be waiting periods to serve before you can fully benefit. Once your waiting period is over, you can use your insurance to claim for prescription glasses or contact lenses. Simply file a claim with your health fund, and you can reduce your out-of-pocket costs significantly.

Optical Services Typically Covered

When you purchase optical coverage, the following services are typically covered:

Prescription Glasses and Contact Lenses
Prescription glasses are designed to correct vision and help you see better. If you prefer contact lenses instead of glasses, both options are covered under optical insurance. Whether you choose glasses or lenses, your optical coverage will help reduce the cost.

Prescription Sunglasses
For those whose vision is affected by sunlight, prescription sunglasses may be necessary. These are covered under optical insurance as well. However, it’s important to note that non-prescription sunglasses are not covered under health insurance.

Understanding Costs and Benefits

There are quite a few costs and benefits associated with optical cover, which are as follows:

Annual Limits 

These limits are the total coverage that you can claim within a year. Most health fund annual limits reset with the start of the new calendar year, but discuss the reset date with your health fund. For example, if you have an annual limit of $250 for optical, you cannot claim more than $250 for an optical in that year. 

Out-of-Pocket Expenses

You would have to pay these expenses out of pocket even after getting an optical cover. They are gap payments that your provider does not cover. If you choose to get your glasses or contact lenses from a retailer that is your health fund’s preferred partner, you might get higher rebates.

Waiting Periods 

The initial duration that starts right after starting an insurance policy during which the policyholder cannot claim or use any benefit of the policy is known as the waiting period for any insurance policy. During this period, the policyholder will have to pay the full amount of any incurred costs for any reason for themselves. The duration of these periods varies from provider to provider and also based on the type of policy you get. In most cases, if you are changing your policy and have already gone through a waiting period, you are unlikely to go through another waiting period. You can read more about the waiting periods on this page. 

Health Fund Rebates 

Once you’ve found your perfect pair of glasses at the optometrist, you’ll then need to pay for them. For most people with health insurance, the sales agent will take your health insurance card and swipe it on their HICAPS machine, this will automatically detect if you’re eligible for any special offers, and it deduct your optical rebate automatically from your extras policy. If there’s any amount owing after the rebate has been deducted, you’ll have to pay this out of pocket.

Choosing the Right Optical Cover

Choosing the right cover is of utmost importance, and here we help you understand how you can do it:

Accessing Your Optical Needs 

It is important to assess your present and future optical needs. Assess whether you need glasses or not. Do you need a new pair? How often do you break your glasses? Do you need contact lenses? What is the possibility of you getting a prescription for glasses in the next three months? Ask yourself these questions to assess your optical needs. Keep in mind that your age and the type of work you do will also play a crucial part in this. As we grow older, our eyes become weaker, and at one time or another, we do need some sort of glasses. Similarly, if your daily work requires a lot of screen time or reading fine print, you may need a pair of glasses. 

Comparing Policies 

Compare different policies to choose the best one for you according to your needs. You can get help from the Compare Your Health  insurance policy comparison tool. This tool can help you find the best possible health fund and policy for yourself while getting the most benefits.

Considering Costs vs Benefits 

Consider your monthly payment and benefits. It is always wise to calculate how much you will be paying out of pocket each month or so for your policy. If you are getting an increased yearly limit but for an additional $40 per month, it may be wise to reconsider this policy. In the same way, if another health fund is offering you the same increased yearly limit for $25, it may be a good deal. Before you settle on a policy, make sure that you have searched the market well. This will help you narrow down the most cost-effective options and enjoy the services with financial security. 

Reading Policy Brochures 

Finally, each health cover policy has a brochure that is deeply explained and helps you understand it in detail. Read that brochure thoroughly before you make a decision. 

Exclusive Benefits on Your Health Fund

In Australia, there are many different optical retailers, each offering a wide variety of products and services to customers. A few of the top optical retailers include Specsavers, OPSM, and Bailey Nelson. Each company has a separate section on its website where it shows specific offers based on your health fund. 

Extras Cover and Optical Insurance

When choosing an extras policy with optical as a consideration, you’ll have a plethora of options to pick from. You want to find a policy that offers great value for money on optical. You might find one policy that gives you $200 per year, and another that gives you $250 per year on optical, but if it costs you an extra $500 in premiums for a year for that extra $50, then it wouldn’t be worth it. 

Make sure you are mindful of your rebate too. Some policies will give you 100% back up to your annual limits, whilst others will give you 60%. Others will pay a certain amount for single-vision lenses and another amount for multi-focal lenses, so make sure you pick a policy that’s right for you and your individual needs.

Optical Care in Australia

Overview of the Optical Care System
The optical care system in Australia is designed to address eye health, vision testing, and corrective eyewear like glasses and contact lenses. This system is divided into two key components: services covered by Medicare (Australia’s public health care system) and services typically covered by private health insurance.

1. Medicare Coverage for Optical Care
Medicare provides limited coverage for optical care, primarily focusing on eye health diagnostics rather than corrective devices such as glasses or contact lenses. Medicare covers certain eye examinations conducted by optometrists, and these services are often bulk-billed, meaning there are no out-of-pocket costs for the patient. For instance, individuals under 65 are eligible for an eye test every three years, while those over 65 are eligible for an eye test annually. Medicare also covers eye tests for conditions like cataracts, macular degeneration, glaucoma, and diabetic retinopathy.

If further specialist care is needed (e.g., visiting an ophthalmologist for surgery or treatment of serious eye conditions), Medicare will cover part of the consultation and treatment fees. However, patients often face additional out-of-pocket costs unless they have private health insurance.

It’s important to note that Medicare does not cover the cost of prescription glasses or contact lenses. Additionally, services such as lens coatings or designer frames are also excluded from coverage.

2. Private Health Insurance and Optical Care
Private health insurance typically offers more comprehensive optical coverage through extras cover (also referred to as ancillary cover). Depending on the policy, this can include prescription glasses, contact lenses, and even a rebate for frames. The amount of coverage you receive will vary based on your specific policy.

Importance of Regular Eye Check-ups
Despite the coverage options available through Medicare and private health insurance, regular eye check-ups remain essential for maintaining eye health. We recommend getting your eyes tested at least twice a year to ensure your vision stays in optimal condition and to catch any potential issues early.

Advanced Lens Options and Treatments

Advanced Lens Options and Treatments

As previously mentioned, private health extras cover provides coverage for a wide range of prescription glasses, lenses, and sunglasses. Below, we’ll take a closer look at some advanced lens options and treatments available:

Thin and Light Lenses
Depending on the glasses provider you choose, you can opt for thin and light lenses, which offer a more comfortable fit. These lenses are often lighter in weight and slimmer than traditional lenses, reducing the bulk and providing a more aesthetically pleasing appearance.

Transition Lenses
Transition lenses are designed to adjust automatically to changing light conditions. They remain clear when indoors and darken when exposed to sunlight, offering convenience and protecting your eyes from UV rays.

Polaroid and Drivewear Lenses
These lenses are ideal for those who drive at night or experience eye strain from simple light sources. Polaroid lenses reduce glare and improve visibility, while Drivewear lenses are specifically designed for driving, adjusting to varying light conditions for enhanced clarity and comfort.

UV Filters and Sun Tints
Glasses with UV filters and sun tints provide your eyes with maximum protection from harmful UV rays. These lenses are especially important for those who spend time outdoors and want to safeguard their eyes from the damaging effects of the sun.

Tips for Maximising Your Optical Cover

To get the most out of your optical coverage, consider the following tips:

Understanding Your Policy Limits
One of the most important steps in maximising your optical cover is understanding what is and isn’t covered by your policy. Be aware of any annual limits on your coverage, as this can influence how much you can claim for glasses, lenses, and other optical services. Make sure to keep these limits in mind when visiting your optical clinic or retailer.

Timing Your Optical Purchases
Since you may only need new glasses once a year or even less frequently, timing your purchases is key to maximising your optical benefits. Many health funds reset their policies at the start of the calendar year, which means your annual cover limit will renew. Use this reset time to get the most out of your optical cover.

Utilising No-Gap Options
When purchasing eyewear, look for no-gap options to avoid out-of-pocket expenses. Many health funds offer no-gap deals with their preferred partners, meaning you can get your glasses or contacts without paying extra. Be sure to inquire about no-gap options with your optical provider to save on costs.

Common Eye Conditions and Their Coverage

Here are some of the most common eye conditions and how they are typically covered by private health insurance:

Refractive Errors (Myopia, Hyperopia, Astigmatism)
Refractive errors such as myopia (short-sightedness), hyperopia (long-sightedness), and astigmatism are common vision problems that can be corrected with prescription glasses or contact lenses. A basic optical cover is usually sufficient to help with the cost of glasses or lenses for these conditions.

Age-Related Conditions
Age-related conditions like glaucoma and cataracts may require a higher level of hospital cover. These conditions often require more extensive medical treatment, such as surgery or ongoing management, which is typically covered under a hospital cover policy.

Eye Trauma Surgeries
In the case of eye trauma, such as injury to the eye that requires surgery, you will need hospital cover. It’s important to check with your health fund provider to understand which specific eye-related surgeries are covered and which tier of coverage applies to these treatments.

Comparing Optical Cover Providers

Different insurance providers offer various types of optical coverage, which is why it’s essential to compare optical covers from multiple providers to find the one that best suits your needs. The Compare Your Health insurance comparison tool is an excellent way to compare different optical cover options. This tool helps you find the best insurance fund and policy that offers the most benefits tailored to your needs.

It’s important to note that Compare Your Health provides accurate information based on your preferences and does not endorse any specific insurance policy. Our goal is to assist you in making an informed decision when selecting your optical cover.

FAQs about Optical Health Insurance

What optical services are covered?
Optical health insurance is a type of private health insurance that covers prescription glasses, contact lenses, and prescription sunglasses. Most health insurance providers offer optical coverage as an additional benefit through their extras cover.

How do claims work?
Once you have paid for your optical treatment, you can file a claim with your health fund for reimbursement. Your health fund will process the claim and refund the amount they cover based on your policy. To submit a claim, you can either call your health fund directly or use their website or mobile app to file your claim online.

Compare now

In conclusion, health insurance with optical cover can be incredibly beneficial if you have optical needs. The best way to choose the right insurance provider is by using the Compare Your Health Insurance Comparison tool. Here, you can compare different health funds offering optical cover plans, costs, and providers.

Need Expert Advice?

if you need expert guidance,feel free to reach out to us:

Contact: Compare Your Health
Email: info@compareyourhealth.com.au
Phone: 1300 631 373

Get in touch with our experts for tailored advice and support in making informed health insurance decisions for you and your loved ones.

Nice dark haired woman using the optical instrument

Related Articles

  • Pros and Cons of Private Health Insurance in Australia

Frequently Asked Questions

Depending on the policy, private health insurance can help cover the cost of your medical treatments in or out-of-hospital that Medicare sometimes won’t cover. Out of hospital treatment can include services such as Dental, optical, physiotherapy or even remedial massage

Private health insurance can help cover medical treatment received when hospitalised. Therefore, it is important to select the right level of cover for the clinical categories that are necessary to you.

Your private health insurance should change as often as needed to ensure you are covered at all the different stages of your life.

Also, private health insurance gives you the ability to choose your own doctor and avoid any public waiting lists for categories covered by your policy.

There are many top competing health funds, however you want to find one that is best suited to your individual health requirements and not just a health fund that is the best in the market.

This can sometimes be a difficult task for individuals, therefore companies like Health.Compare can offer comparisons of different health insurance policies to help you choose a policy that is catered to your health circumstances and budget.

Excess is the amount you pay upfront to cover some of the hospitalisation expenses if you ever get hospitalised. The higher the excess, the lower your private health insurance premiums will be. This usually applies to people with relatively lower health concerns who do not see themselves being in hospital anytime soon and in the event that they are hospitalised, they can agree to pay a higher excess, ultimately reducing their regular premiums.

Please be aware that excess amounts do vary depending on the health insurance provider, so it may be beneficial for you to consider your individual health and financial circumstances at the time of buying the insurance policy before agreeing to the Excess amount.

In Australia, health insurance is not tax deductible however you can receive rebates for your private health insurance. When taking out Private Health Insurance you choose whether or not to claim a rebate from the government. The government rebate is dependent on a number of factors including age and taxable income.

This can be applied to Hospital, Extras or combined products.

According to a recent report by APRA, 55.2% of Australians have extra cover, and 45.2% have hospital cover. These are the verified figures as of June 2022.

While the average cost of private health insurance adds up to $160 per month per person, your premiums may go up or down depending on the type of cover you choose or the excess amount you agree upon.

The starting point for many, is to look at your individual needs, preferences and financial circumstances.

We will help guide you through this conversation by first understanding and then matching your needs to a tailored level of cover. Ultimately, what’s best for you and your situation will be completely different to many others who are eligible for Private Health Insurance.

Yes you can have a private hospital insurance policy with one health fund and extras cover with another. This can be helpful as some funds might have a hospital policy you like, but not the extras cover you require for the specific out-of-hospital treatments.

Private health insurance provides many benefits to its members giving them access to a wide choice of health providers, faster access to medical services and the ability to avoid long wait times experienced in the public hospital system. In this FAQ we will answer some of the common questions about private health insurance.

What are the benefits of having private health insurance?

  • Access to private hospitals and faster treatment times
  • A wider range of treatment options
  • Ability to choose your own doctor and hospital
  • Reduced out-of-pocket expenses
  • Access to many health services and treatments not covered by the public system

Can I choose my own doctor and hospital if I have private health insurance?

Yes, with private health insurance you have the ability to choose your own doctor and hospital, giving you greater control over your health care to achieve a better overall health outcome.

How can I choose the right private health policy for me?

When choosing private health insurance, there are a few factors to consider:

type of cover required (hospital or extras)

  • your budget
  • your age and pre-existing medical conditions
  • the level of cover required
  • the range of health services you need to be covered for

Why should I get extras cover?

extras cover will give you further coverage on a range of treatments such as dental, optical, chiropractic, massage and physiotherapy.
some extras health policies also include further natural therapies such as acupuncture and Chinese medicine

How much does private health insurance cost?

The cost of a health policy in Australia varies depending on what type of cover you choose, your age, if you have any dependents and any pre-existing conditions. On average, the cost of private health insurance is around $2,000 per year for an individual and $4,000 per year for a family.#

In Australia, private health insurance is available to provide financial protection and contribution to medical expenses, but not all medical expenses are covered by your private health policy. In this FAQ we will explain the questions you have around what is typically covered and what’s not covered with private health insurance.

What is not covered by standard private health insurance?

The most common exclusions from private health insurance policies in Australia include:

  • Elective cosmetic operations, such as cosmetic surgery and cosmetic dentistry
  • Weight loss surgery, unless it is deemed medically necessary
  • Infertility treatments, such as IVF
  • Alternative therapies, such as homeopathy, aromatherapy, kinesiology, reflexology and iridology
  • Mental health services, such as counseling and psychotherapy, unless they are part of a hospital treatment plan
  • Non-medical services, such as transportation and accommodation for medical treatment
  • International travel for medical treatment
  • Experimental treatments or procedures that are not yet widely accepted or covered by Medicare

Does private health insurance cover dental services?

No, private health insurance does not generally cover routine dental services, such as check-ups, cleanings, and fillings. However, some private health insurance policies may offer coverage for more extensive dental procedures, such as orthodontics and oral surgery, that are performed in a hospital setting.

Does private health insurance cover optometry services?

Similar to dental, optometry services are not covered by private health insurance such as eye examinations although prescription glasses and contact lenses are covered by private health extras policies.

Am I covered for ambulance services?

Not all private health policies cover individuals for ambulance services. However, some states in Australia automatically cover policy holders through their state or territory.

Will my private health policy cover prescription drugs?

No, private health insurance policies in Australia do not cover prescription drugs. Prescription drugs are covered by the Pharmaceutical Benefits Scheme (PBS), which is a government-funded program.

In conclusion, it’s important to understand what is not covered under your policy to avoid any surprises when you need to make a claim. While most health insurance policies provide coverage for a wide range of medical expenses, there are still some things that are not covered, and it is important to understand these exclusions.

So, you have private health insurance and want to know how much you might have to pay for medical treatments out of your own pocket? We’ve got you covered with our easy guide FAQ.

What does ‘no gap’ mean when it comes to private health insurance?

Basically, it means that you won’t have to pay anything out of your own pocket for certain medical services, these are covered by your private health insurance. It’s the difference between what your doctor or hospital charges and what Medicare and your private health fund will pay and it’s known as the ‘gap’. With a ‘no gap’ arrangement, your insurance will cover the full cost of the service.

So, I won’t have to pay anything extra?

That’s right! With the ‘no gap’ arrangement, you won’t be left with any unexpected bills to pay. Your private health insurance will cover the full cost of the medical service, so you can focus on your health and recovery.

How does it work?

To be eligible for a ‘no gap’ service, you’ll need to use a provider who is part of your private health insurance provider’s ‘preferred provider’ network. This means that the provider agrees to charge you a set fee for a particular medical service, and your private health insurance will cover this fee in full. This way, you can be sure that you won’t have to pay anything out of your own pocket.

Can I get ‘no gap’ for any medical procedure?

Unfortunately, ‘no gap’ is only available for some medical services, and only if you use a provider who is part of your private health insurance provider’s ‘preferred provider’ network.

Is ‘no gap’ the same as ‘bulk billing’?

No, they’re not the same thing. ‘Bulk billing’ is when medical providers bill Medicare directly for their services, so you don’t have to pay anything out of your own pocket. ‘No gap’ is a service that’s offered by private health insurance providers, and it covers the full cost of certain medical services.

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