The Ins and Outs of Optical Health Insurance in Australia

Published: October 11, 2018

Whether you need new prescription glasses or want to book an eye test, you might be wondering how much Medicare will pay and if they’ll cover the costs of your chosen optometrist.

Medicare does not usually cover eyeglasses and contact lenses. To avoid out-of-pocket costs, you might want to look for health insurance with optical cover.

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Does Medicare cover eye care?

If you have a Medicare card and go to an optometrist that is registered with the Optometry Board of Australia, Medicare will usually cover some of the costs for consultations on vision-related problems that are defined as clinically relevant. Benefits are generally payable at 85% of the Medicare Benefit Scheme (MBS) for optometry fees.

However, since 1 January 2015 optometrist can set their own prices, so you might have to pay more and there have been some changes regarding how often you can have a bulk-billed eye test:

Under the age of 65

A benefit is only payable once every 3 years.

65 years and older

A benefit is payable once every 12 months.

If you wear glasses or contact lenses, you know that your eyesight changes all the time, which is why it’s usually suggested you have an eye exam every year.

Optometric services not covered by Medicare, include:

  • Surgery that corrects common vision problems,
  • Cosmetic eye surgeries,
  • Eye test required for obtaining any commercial licence, like flying or driving,
  • Vision screenings,
  • Examinations for entrance to schools or other educational facilities,
  • Eye exams for admissions to aged care facilities, and
  • Tests to determine your ability to undertake certain sports or vocational activities.

How much is a typical eye exam without health insurance?

Without Medicare or private health insurance extras, a comprehensive initial consultation by an optometrist is generally $66.80. If you have a Medicare card, you'll generally only pay $10 because they'll cover 85% of the fee ($56.80). However, because optometrists can now set their own prices, you might be charged more. For example, a comprehensive eye test from Specsavers generally cost about $71.

Take note; Medicare benefit payments for the above are only valid if you've not gone for an eye test within the last 36 months when under 65, or last 12 months when 65 years and older.

You may need to have more frequent eye tests if you:

  • Are short-sighted or long-sighted.
  • Have blurred or distorted vision at all distances.
  • Suffer from glaucoma.
  • Have cataracts.
  • Have retinal detachment.

You might also want to get your child’s eyes tested before they start school, so that vision problems can be detected early on and not interfere with their learning ability.

Optical health insurance explained

Different extras policies and providers will provide different levels of coverage, waiting periods and benefit limits.

Cover: If you have private health insurance with extras, your policy will usually subsidise your prescription glasses, prescription sunglasses and contact lenses up to your benefit limit.

Benefit limits: Many insurers have limits as to how much they will cover for your lenses and frames, usually set as a percentage or specific amount.

Waiting periods: Generally, you’ll have to serve a waiting period of 2 to 6 months before you can claim this benefit, depending on the insurer.

Compare Optical Insurance Offers

How to find the best health insurance for optical

Most private health funds provide extras that offer some level of optical coverage. However, the amount or percentage depends on the extras option you choose. You may want to consider your family dynamic, health, age and budget to help you find a policy that’s best suited to your requirements.

Below are some Australian health insurers that provide extras cover for prescription spectacles, contact lenses and eye exams.

Compare optical cover options

Health fund Waiting period Benefit limit Cost per month
Australian UnitySilver Extras 6 months $200 $66.10
AHMBlack 70 6 months $200 $59.70
BUPASilver Extras 2 months $200 $69.50
CBHSIntermediate Extras 6 months $250 $48.62
Defence HealthValue Extras 2 months $255 $65.56
GMHBASilver Extras 6 months $200 $53.93
HCFSilver Plus Extras 2 months $200 $41.95
MedibankGrowing Family 60 Extras Only 6 months $200 $49.15
NibCore Extras Plus 6 months $300 $58.73
Teachers Health FundEssentials Extras 6 months $165 $50.92
Source: Privatehealth.gov.au (October 2018)

The above table is calculated on a single adult living in QLD wanting to purchase mid-level extras coverage.

Before choosing a private health fund, you might want to compare quotes from top health insurance companies in Australia to determine which insurer will provide you with the best value for money optical cover.

Frequently asked questions and answers

Can I get optical health insurance with no waiting period?

No, waiting periods for extras like optical coverage are generally mandatory on all private health insurance policies. However, how long you must wait before you can claim for prescription glasses, contact lenses or eye exams depend on the health fund you’ve chosen.

Does health insurance cover laser eye surgery?

Lasik surgery for vision correction is not typically covered under Medicare unless it's medically necessary. You might be able to use private health insurance to reduce the cost of this expensive procedure. However, this is entirely dependent on the insurer and level of cover you choose; basic hospital, mid, or top hospital cover.

What about serious eye problems?

For eye problems needing surgery or eye illnesses requiring treatment in-hospital, you’ll need to purchase a hospital health insurance policy that covers procedures such as cataract surgery.

Can I claim sunglasses on health insurance extras?

Prescription sunglasses are generally covered under optical insurance from private health funds. Depending on your level of cover, basic, mid or top, and your insurance provider, you’ll receive a full or partial rebate. However, non-prescription shades are usually not covered.

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