Infertility and Assisted Reproductive Services
Infertility is defined as the inability to conceive after one year of regular, unprotected intercourse. Infertility can be caused by many factors, including genetic, medical, surgical, or trauma related causes in either the male or female or both. Equally, there is a range of assisted reproductive treatments available to assist in treating the condition.
In Vitro Fertilisation (IVF) treatment and Gamete Intra Fallopian Transfer (GIFT) are two of the procedures for treating infertility which are most commonly covered by private health funds.
Choosing a Hospital Policy
Assisted reproductive services are not covered by all health insurance policies. Always check with your fund before proceeding with IVF or similar treatments to confirm whether you are covered for these services, whether there are services you will be required to pay for yourself, and whether you have completed any required waiting periods. If your current policy doesn’t include Assisted Reproductive Services, you will need to upgrade your policy.
Waiting periods apply when you take out or upgrade your hospital policy. Australian funds apply the following maximum waiting periods:
- a two month waiting period for any benefits;
- a twelve month waiting period for benefits for pre-existing conditions; and
- a twelve month waiting period for benefits for obstetrics (maternity) services.
As infertility is generally defined as the inability to conceive after one year, assisted reproductive services will usually be subject to the twelve month waiting period for pre-existing conditions. This means you need to complete twelve months of membership on an appropriate hospital policy prior to the commencement of IVF treatment in order to be eligible for benefits.
If you do need treatment within the first twelve months of taking out or upgrading your policy, your fund will assess whether your condition is a pre-existing condition and therefore, whether benefits are payable. You will need to ask your treating doctors to complete a medical certificate supplied by your fund to assist the fund’s medical adviser in determining whether your condition is a pre-existing condition or not.
It’s important to note that it is the fund’s medical adviser that makes this decision and not your treating doctors. The fund medical adviser will take account of information provided by your treating doctors in making his or her decision. You should ensure this assessment has been completed before you are admitted to hospital for treatment. Otherwise, you may be liable for the cost of the admission if benefits are denied by your fund on the basis of the pre-existing conditions rule. For more information about waiting periods, see PHIO’s “Waiting Periods” brochure.
Some funds also include Benefit Limitation Periods as a feature of some of their hospital policies. These are initial periods of membership during which only a minimal benefit is paid for some types of treatment. These Benefit Limitation Periods may be from one to three years, depending on the policy. Check with your fund for more information.
What’s covered by private hospital insurance?
It’s important to know that that for IVF treatment, like most other medical treatments, only in-patient services (where you are formally admitted as a private patient to the hospital) that have a valid Medicare item number will attract a benefit from your health fund.
This means that if there is no Medicare item number for the service or treatment, your fund may not pay any benefits towards the cost of the procedure. The hospital should advise you prior to admission about any costs you will incur for the procedure and obtain your informed consent to incurring the charges.
Generally, the main surgical procedure in an IVF cycle is the egg collection. This procedure is also referred to as egg pick-up, oocyte pick-up, OPU, and sometimes egg harvesting. As this procedure is carried out in an operating theatre, you will be admitted as an in-patient to hospital. If your policy covers Assisted Reproductive Services, then the hospital accommodation and theatre fees will be covered by your health fund. Your fund will also provide a benefit towards your anaesthetist and treating doctors’ fees. You may have to pay part of the medical fees yourself (the portion charged above the Medicare Benefits Schedule fee, known as the ‘gap fee’) – check with your doctor for more information.
In some cases, you may also be admitted as an in-patient for the embryo transfer procedure. If this is the case, the same benefits as described above will apply.
What isn’t covered by private health insurance?
There are many components to IVF treatment and some of the associated services occur outside of a hospital admission (out-patient services). These services include consultations with your clinic and doctor, scans, ultrasounds, some diagnostic procedures and pathology services. Some of these services may be claimable through Medicare and some will be at your own expense. There are also additional costs associated with egg transportation, testing and freezing that may be at your own expense.
IVF treatment also includes the use of IVF drugs. Not all drugs will attract a benefit from Medicare. Drugs that are not covered by Medicare include, but are not limited to, Lucrin, Provera, Synarel, Orgalutran and progesterone pessaries. Your health fund may provide a benefit toward the cost of some of the IVF related drugs. It’s important that you contact your health fund to discuss what benefits are payable toward the IVF drugs specific to your treatment.
To help determine what you will be covered for, we strongly recommend you ask your IVF clinic for a detailed quote of your expected treatment plan, including all medical item numbers. Take this information to your fund – having this quote will assist your fund in being able to accurately advise you about how you are covered and what costs you are likely to incur.
To check and upgrade your cover, contact your health insurer.
For general information about private health insurance and to compare health insurance policies, contact the Private Health Insurance Ombudsman at:
- 1300 737 299
If you have a complaint about your health fund, you may wish to contact the Private Health Insurance Ombudsman on 1300 362 072 or www.ombudsman.gov.au.