What is Optical Health Insurance?

Optical health insurance is private health insurance that covers solely prescription glasses and contact lenses. Most health insurance companies offer optical coverage as an additional coverage. Getting optical coverage can be very beneficial for you if you wear prescription glasses or are looking for contact lenses. This type of insurance helps with the cost of glasses, frames, lenses, and the costs associated with the repair of the glasses. 

How Optical Cover Works?

Optical cover works exactly as any other health fund insurance policy. You first buy an optical cover as a part of the extras cover. Depending on your policy, you will then need to serve any waiting periods. You can then use your insurance to get prescription glasses or contact lenses and can file a claim with your health fund. 

The following services are mostly covered when an optical coverage is purchased:

Prescription Glasses and Contact Lenses 

Prescription glasses are any glasses prescribed to maintain vision or help you see better. You may choose to get lenses in place of glasses, and both will be covered under optical insurance. 

Prescription Sunglasses 

Some people’s vision may be affected by sunlight, in which case they are prescribed sunglasses, which are also covered under optical coverage. Unfortunately, non-prescription sunglasses are not covered under health insurance.

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 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 Health Deal’s 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. 

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.

Overview Optical Care System 

The optical care system in Australia consists of services that involve eye health, vision testing, and corrective eyewear like glasses and contact lenses. The system is divided into two main components: services covered by Medicare (Australia’s public health care system) and services often covered by private health insurance.

1. Medicare Coverage for Optical Care

Medicare provides limited coverage for optical care, focusing mainly on eye health diagnostics rather than corrective devices (like glasses or contact lenses). Medicare covers certain eye examinations conducted by optometrists. Under Medicare, these services are often bulk-billed, meaning the patient doesn’t pay out of pocket. For example, people under 65 can get an eye test every three years, and those over 65 can get one every year. Eye tests for issues like cataracts, macular degeneration, glaucoma, and diabetic retinopathy are also covered. If there is a need for further specialist care (e.g., an ophthalmologist for surgery or serious eye conditions), Medicare will cover part of the consultation and treatment fees, but patients often face out-of-pocket costs unless they have private health insurance.

However, Medicare does not cover the cost of prescription glasses or contact lenses. Also, things like lens coatings or designer frames are not covered.

2. Private Health Insurance and Optical Care

Private health insurance typically provides more comprehensive coverage for optical care through extras cover (also known as ancillary cover). Depending on the policy, this can include prescription glasses and contact lenses. Most private health insurance policies with extras cover offer rebates for prescription glasses, frames, and contact lenses. The amount covered varies depending on your policy. 

Importance of Regular Eye Check-ups 

Despite all the above, we cannot emphasise the importance of regular eye check-ups enough. We recommend getting your eyes checked at least twice a year for maximum health benefits. 

As discussed, private health extras cover offers coverage for a variety of prescription glasses, lens options, and sunglasses. Here, we discuss them in a little more detail. 

Thin and Light Lenses 

Based on the glasses vendor you go to, you can get thin and light lenses that sit more comfortably on your face and may offer additional benefits. 

Transition Lenses

Transition lenses are designed to go clear indoors and automatically become darker when outside in the sun.  

Polaroid and Drivewear Lenses

These are best for driving at night or when simple light strains your eyes. 

UV Filters and Sun Tints

These types of glasses offer your eyes maximum protection from the sun.  

Following are some tips to maximise the use of your optical cover:

Understanding Your Policy Limits

Understanding what is covered by your policy and what is not is one of the most important points in maximising your cover benefits. There might be an annual limit on your policy so make sure that you keep them in mind when visiting your optical clinic or retailer. 

Timing Your Optical Purchases

As you may require a pair of new glasses once a year or less, timing your optical purchases is key to maximising your optical benefits. Remember, most health funds reset the policies at the start of the calendar year and have annual cover limits. Use the reset times to your advantage.

Utilising No-Gap Options

While purchasing eyewear, look for no-gap options so you do not have to pay any out-of-pocket costs. You can also choose your health fund’s preferred partners, who may offer you no-gap options for your glasses or contacts. 

Some of the most common eye conditions and their coverage are as follows:

Refractive Errors (Myopia, Hyperopia, Astigmatism)

Myopia is short-sightedness, hyperopia is long-sightedness, and astigmatism is a type of refractive error. All these conditions can be helped with the use of prescription glasses. A basic optical cover might be able to help you with all these conditions. 

Age-Related Conditions 

Age-related conditions like glaucoma or cataracts will need a higher level of hospital cover. 

Eye Trauma Surgeries

For eye trauma surgeries, you will need a hospital cover. You will need to talk to your health fund provider to carefully assess which eye-related surgeries they cover and under which tier of coverage. 

Different insurance companies offer different sorts of optical covers. This is why it is always best to compare optical covers from various providers to assess the one that works best for you. The Health Deal’s insurance comparison tool is a good way to compare insurance. This tool can help you find the best possible insurance fund and policy for yourself while getting the most benefits. It is important here to mention that Health Deal only provides accurate information at your discretion and does not endorse any insurance policy. 

What optical services are covered?

Optical health insurance is private health insurance that covers solely prescription glasses, contact lenses, and prescription sunglasses. Most health insurance companies offer optical coverage as an additional coverage. 

How do claims work?

After you have paid for the treatment, you will file a claim with your health fund, who will process your claim and rebate you the amount they cover. To file a claim, you can call your health fund directly or submit a claim through their website or phone app. 

In conclusion, health insurance with optical cover can be very beneficial for you if you have optical needs, and the best way to choose your insurance provider is by using the Health Deal Insurance Comparison tool. You can compare different health funds that offer optical cover plans, costs, and providers here. For expert advice, you can contact Health Deal at enquiries@healthdeal.com.au. You can speak to our experts at 1300 369 399 or fill out the online form here. Get in touch now to speak with an insurance expert for tailored advice and support in making viable health policy decisions. 

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