Extras limits and annual caps

Extras cover rarely pays the whole fee: each service usually has a benefit per visit and a yearly limit, and some services share a combined limit or carry a lifetime one. Once a limit is used up, the policy pays nothing more for that service until the limit year resets.

General informationThis page explains how extras limits work in general; it does not describe any fund’s limits. It is not financial advice. The definitions are in privatehealth.gov.au’s glossary, and your own policy’s limits are on its Private Health Information Statement.

Five kinds of limit

Nearly everything under extras is covered only to a limited extent, and a policy can stack several limits on the same service. These are the terms privatehealth.gov.au uses.

Benefit per service: What you can claim for one service, shown as a dollar maximum (up to $50 a visit, say) or a percentage (up to 75% of the cost), or a mix of both. The mixed kind is not currently displayed on the Private Health Information Statement, so the insurer is the place to ask.
Annual limit: The most the policy pays for a service in a 12-month period.
Combined limit: One amount shared across a group of services: claims for any of them come out of the same pool.
Sub-limit: A cap for one service inside a larger limit, deducted from that larger limit.
Lifetime limit: The most the policy pays for a service for the whole of your membership.

A year of physio, itemised

Example only · invented figures

A fictional extras policy has a combined limit of $600 a year for physiotherapy, chiropractic and osteopathy, with a sub-limit of $400 for each. It pays 60% of the fee, up to $45 a visit. Each physio visit costs $90, so 60% would be $54, and the $45 cap applies.

One limit year, claim by claim
Claim	Fee	Fund pays	Sub-limit left	Combined left
Physio, visit 1	$90.00	$45.00	$355.00	$555.00
Physio, visit 2	$90.00	$45.00	$310.00	$510.00
Physio, visits 3–8	$540.00	$270.00	$40.00	$240.00
Physio, visit 9	$90.00	$40.00	$0.00	$200.00
Physio, visit 10	$90.00	$0.00	$0.00	$200.00
Chiro, visit 1	$80.00	$45.00	$355.00	$155.00
Physio, the year	$900.00	$400.00	$500.00

Three things happen on that receipt. The per-visit cap means you pay $45 of every early visit. The physio sub-limit runs out on visit 9, so that visit pays only the $40 left and visit 10 pays nothing. And the physio claims also ate $400 of the shared $600, leaving $200 for chiropractic and osteopathy together, even though their own sub-limits are untouched.

The structure follows the example on privatehealth.gov.au’s glossary: a combined limit with a sub-limit for each service means the most you can claim for one service is its sub-limit, and whatever is left of the combined amount can go to the others.

When the year resets

“A year” is not the same for every policy. An annual limit can run by calendar year, by financial year, or for each 12-month period from the anniversary of when you took out the policy. Two people with the same limit can therefore reach a fresh year months apart, and your insurer can say which applies.

A change of fund can also affect the count: the new insurer may take into account benefits your previous insurer paid when it works out your annual limits. For lifetime limits, the new insurer may deduct what you have already claimed. The switching receipt has the full list of what carries over.

Things that change the line

Preferred providers. Some insurers have arrangements with extras providers to pay a higher benefit than for a provider outside the network. Each insurer has its own network.
Loyalty schemes. Some insurers raise the annual limit or the benefit for long-term members. These are generally not transferable if you change insurers.
Health aids. Benefits for items such as hearing aids and blood glucose monitors may come out of an overall health aid limit.
Pharmacy. Pharmaceutical benefits usually require you to pay a co-payment equal to the normal PBS payment before the insurer pays, and not every non-PBS medicine is eligible.
Dental. Whether an item counts as general or major dental depends on each insurer’s rules.
Optical. Insurers don’t pay for optometrists’ consultations, because those are generally eligible for Medicare.

What extras can’t pay for

Private health insurers can’t cover out-of-hospital services that are on the Medicare Benefits Schedule, such as GP or specialist appointments, pathology or diagnostic imaging. They can cover some services Medicare doesn’t, like physiotherapy and other allied health.

Since 1 April 2019, insurers have not been able to pay benefits for a list of natural therapies, including aromatherapy, homeopathy, naturopathy, Pilates, reflexology, tai chi and yoga.

Waiting periods for extras are set by each insurer rather than by a government maximum.

Where the limits are written down

Every policy has a Private Health Information Statement. For extras it lists the services covered, waiting periods, benefit limits and example benefits for each type of service. Each covered service includes an example of the maximum benefit you can claim for common treatments. The comparing receipt walks through one.

A statement is only a summary, though; the Department of Health suggests contacting your insurer for all the details of a policy.