How Health Insurance Works FOR DENTAL SURGERY (Hospital vs Extras Explained)
- Dr Andrew Chan
- Jan 31
- 8 min read
Updated: Feb 2
Trying to understand what your private health insurance actually covers is confusing.
Most Australians might know they have private health insurance. But most will not know what they are actually covered for, especially when it comes time for dental treatment, dental surgery or oral surgery.
This guide explains how health insurance works in Australia, specifically in relation to the services we provide at Adelaide Tooth Removals & Dental Implants: for example wisdom teeth, tooth extractions, dental implants, All-on-4 dental implants, and implant-supported dentures.
There Are Two Types of Private Health Insurance in Australia: Hospital Cover & Extras Cover.
Private health insurance is made up of two different types of health insurance:
Hospital Cover
Extras Cover
They do very different things, and for many dental and oral surgery procedures, both can apply at the same time.
What Is Hospital Cover
Hospital cover is designed primarily for medical surgery in a private hospital or private day surgery. It is not designed for dental surgery. Its main purpose is to cover you whenever you’re admitted as a private patient to a private hospital or day surgery for medical surgical treatment.
In general, hospital cover contributes to the facility and costs associated with being admitted for medical surgical procedures.
The Distinction Between Medical Surgery and Dental Surgery
Medical Surgery is covered by Hospital Cover. Medical Surgery includes:
Orthopaedic surgery (e.g. knee or shoulder surgery)
General surgery (e.g. gallbladder, hernia, appendix)
Gynaecological procedures
Urological procedures
ENT surgery
Cardiac procedures
Gastrointestinal endoscopy and colonoscopy
Obstetrics (for policies that include pregnancy)
Plastic and reconstructive surgery (where medically indicated)
Cancer
Major trauma
Major illnesses
Dental Surgery is covered by Extras Cover. Dental Surgery includes:
Fillings
Crowns
Root Canals
However, Hospital Cover pays for some day surgery and hospital fees regardless of whether the treatment is dental or medical.
When you are admitted to a day surgery or private hospital (regardless of having medical or dental treatment) hospital cover typically helps pay for:
Operating theatre fees
Anesthetic fees
Hospital accommodation (same-day or overnight)
Nursing care
Equipment and sterilisation
Recovery room care
Some materials and components used in your surgery
Exactly what is covered depends on your policy tier (Basic, Bronze, Silver, Gold).
What Hospital Cover Pays For In Relation to Dental Surgery.
Hospital cover will pay for your day surgery or private hospital fees, and most of your anaesthetic fees when dental surgery is performed in an accredited day surgery or accredited private hospital.
Hospital Cover doesn't actually cover any of the dental surgery fees. It is Extras Cover that may cover some of the dental surgery fees.
Most dental surgery is not performed in a day surgery or a private hospital. For example, fillings, crowns, and root canals are almost always performed in a dental practice, not in a day surgery or private hospital.
At Adelaide Tooth Removals & Dental Implants, the following procedures are commonly performed under general anaesthetic in a Day Surgery or Private Hospital:
Full mouth extractions
All-on-4 / All-on-X implant bridge surgery
If these procedures are performed in a day surgery or private hospital, your Hospital Cover will help pay for the day surgery / private hospital and anaesthetic fees. Your Extras Cover will help pay for the dental surgery fees, for example, the wisdom teeth extraction fees.
If these procedures are performed in our dental practice, your hospital insurance is not 'activated' and does not cover any costs. Your Extras Insurance will still cover the dental surgery fees, however.
What Extras Cover Is - And It’s Not Just Dental
Extras cover helps pay for treatment outside of a Day Surgery or Private Hospital and includes much more than dental.
Extras Cover often contributes toward:
Dental treatment
Optical (glasses and contacts)
Physiotherapy
Chiropractic
Osteopathy
Podiatry
Psychology
Remedial massage
Dietetics
Speech therapy
How Extras Cover Applies to Dental Surgery, Wisdom Teeth, Tooth Extractions, Dental Implants & Dentures
Extras Cover may contribute towards nearly all aspects of dental surgery, for example:
Dental checkups, consultations, examinations
Cleans
XRays
Fillings
Crowns
Root Canals
Teeth Extractions
Dentures
However, extras cover has:
Annual limits
Waiting periods
Percentage rebates
Separate major dental caps
For wisdom teeth, tooth extractions, dental implants, All-on-4 implant bridges, and implant-supported dentures in Adelaide, extras usually only cover a portion due to these caps.
Hospital Insurance usually has an excess. Extras Cover doesn’t.
When you use hospital insurance, you often have to pay an excess first.
An excess is a set amount of money you pay out of your own pocket before your insurance kicks in. Think of it like an entry fee to use your hospital cover.
For example, if your hospital excess is $500, you will pay the first $500 to your insurance compan to 'active' your hospital cover. After that, your insurance helps cover the remaining hospital and theatre costs.
This usually applies when you’re admitted to a private hospital or day surgery for procedures that require things like:
A hospital bed
Operating theatre
Nursing care
An anaesthetist
Hospital Insurance cover can range from $0 to $1000, depending on your policy. We find that most people's hospital insurance excess is $500. However, a child or dependent on a family insurance policy usually has $0 excess. Also, you only ever pay your excess once per year.
On the other hand, Extras Cover does not have an excess.
With Extras Insurance, you don’t pay an entry fee before claiming. Instead, you simply:
Pay for your treatment
Claim your rebate
Receive a set benefit back from your insurer (up to your annual limits)
This is how Extras works for services like dental, physio, optical and similar treatments.
So in simple terms:
Hospital cover → you often pay an excess before insurance helps
Extras cover → you claim straight away with no excess to pay
Why Your Rebate Is Difficult to Predict
Every fund, every policy and every level of cover is different. Two patients with the same fund can get very different rebates.
The only way to know is to:
Get item numbers from your dentist
Call your insurer (or get your dentist to swipe your insurance card)
Note:
They will not quote without item numbers.
They will not allow the dentist or dental practice staff to call on your behalf.
Dental Surgery Item Numbers
A dental item number is a standard code from the Australian Dental Association (ADA) Schedule that describes exactly what treatment was performed. Think of it like a universal label for a procedure.
For example:
011 — Comprehensive oral examination
022 — Intraoral periapical X-ray
037 — Orthopantomogram (OPG panoramic X-ray)
311 — Uncomplicated tooth extraction
314 — Removal of tooth or tooth fragments
322 — Removal of impacted tooth (soft tissue impaction)
324 — Removal of impacted tooth (full bony impaction)
684 — Placement of dental implant fixture
These numbers are used by:
Dentists when preparing treatment plans and invoices
Health insurance funds when calculating your rebate
Patients when calling their insurer to ask, “What will I get back?”
Your health fund does not work off descriptions like “wisdom teeth removal” or “implant.” They work off item numbers.
That’s why, before treatment for wisdom teeth, teeth extractions, dental implants, All-on-4 implant bridges, or implant-supported dentures, you should ask your dentist for a treatment plan with item numbers — so your insurer can give you an accurate rebate quote.
Helping You Understand Your Costs Before Treatment
At Adelaide Tooth Removals & Dental Implants, we work closely with you to estimate your likely out-of-pocket costs before treatment, so there are no surprises.
We’re very experienced in helping patients understand how hospital cover, extras cover, item numbers, and insurance rebates all fit together. If health insurance feels confusing, you’re not alone — we guide you through it step by step and help you make sense of what your policy will (and won’t) contribute toward your care.
We recommend that most of our patients DO NOT routinely take out Extras Cover. As it's not worth it most of the time.
Why Extras Cover Often Doesn’t Add Up Financially
Many people take out Extras cover thinking it will “pay for the dentist,” physio, glasses, and other routine care. But when you look closely at how these policies work, the numbers often don’t stack up.
Extras policies usually come with:
Modest annual limits (for example, $500–$1,000 per category)
Fixed rebates that don’t keep up with rising fees
Waiting periods and item restrictions
Annual premiums that commonly total $800–$1,500 or more
What we frequently see is patients paying well over $1,000 per year in Extras premiums, but only claiming back a few hundred dollars. In many cases, they would have been financially better off putting that premium money into a separate savings account and using it to pay for their routine dental, optical, or physio expenses directly.
At Adelaide Tooth Removals & Dental Implants, this is why we often tell patients that Extras Cover doesn’t make financial sense for most people — unless they are very organised and consistently maximise every benefit category, every single year.
Another important factor is how many large health funds are structured. Most of the bigger, well-known insurers in Australia, such as Bupa and Medibank, are for-profit companies that turn multimillion-dollar profits per year. Their main responsibility is to shareholders, not members or customers. This means premiums, benefit structures, and rebate levels are ultimately designed within a system that must generate profits. If an insurance company is making millions of dollars in profits, it's members are losing millions of dollars in unclaimed rebates.
This doesn’t mean these companies are doing anything wrong — but it does mean the system is not purely built around saving customers money. The system is built to make the insurance company a profit.
Extras Cover is not really insurance. It's pre-paying for treatment that you will likely, rarely completely use up before it expires.
If patients do want Extras cover, we generally suggest considering not-for-profit health funds, which exist solely to serve members rather than shareholders. Examples include:
HCF
HBF
Teachers Health
Nurses & Midwives Health
Police Health
GMHBA
Pheonix Health
These funds are typically more transparent, simpler in their benefits, and structured to return value to members rather than profits for shareholders.
By contrast, Hospital cover serves a very different purpose. It protects you from large, unexpected costs — such as hospital fees, theatre fees, and anaesthetist costs — which can run into many thousands of dollars. That’s where insurance provides genuine financial protection and real value. We do recommend that our patients have Hospital Cover.
The Key Takeaways for Patients in Adelaide
Hospital cover helps pay for Day Surgery / Private Hospital fees and Anaesthetic fees for wisdom teeth, extractions, implants and All-on-4 procedures.
Extras cover contributes to the dental treatment and also covers optical, physio and allied health.
We do not recommend that patients routinely take out Extras Cover, as it's not financially worth it for most patients. If Extras Cover is taken out, we recommend looking for a not-for-profit company and policy.
Large procedures like wisdom teeth, dental implants, All-on-4 implant bridges and implant-supported dentures in Adelaide often use both.
Your dentist cannot predict your rebate.
Accurately calculating your private health insurance rebates and out-of-pocket costs is annoying, time-consuming and confusing
You must call your insurer with item numbers.
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