For thousands of Australians who can’t conceive naturally for many reasons (including conditions such as endometriosis and polycystic ovary syndrome), assisted reproductive services may help them achieve their goal of becoming parents. So, does Medicare cover any treatments or costs, and what role does private health insurance play in reducing out-of-pocket expenses?
Yes, provided that you have the right policy, private health insurance covers some of the costs of IVF treatment. Many Australians who struggle with fertility turn to assisted reproductive technology such as In Vitro Fertilisation (IVF) or Gamete Intrafallopian Tube Transfer (GIFT).
These procedures can be expensive, but with the right level of hospital cover, you can reduce your out-of-pocket costs when you’re treated as an inpatient in a private hospital. You will also need to have completed your waiting periods before claiming.
Assisted reproductive treatment involves several steps, and the costs will vary depending on the type of treatment you require.
Day surgery will be required for treatment involving egg collection or frozen embryo transfer. Although the procedures take only hours and don’t require an overnight stay, you’ll need to be admitted into a hospital or facility to undergo treatment.
As with all inpatient services, your health fund can pay a benefit towards assisted reproductive services if you have the right level of cover and are treated as a private patient for a procedure with a valid Medicare item number. Assisted reproductive services are covered under Gold or select ‘plus’ tiered hospital policies. With an appropriate hospital insurance policy, your private health fund can pay a benefit toward your hospital accommodation, theatre fees, treating doctor, anaesthetist and more.
You may still have to pay the gap fee, which is the difference between the Medicare Benefits Schedule (MBS; the fee the government sets as appropriate for the procedure) and what your doctors charge. Some funds have no gap or known gap agreements with certain hospitals and doctors, so make sure you talk to your health fund before receiving treatment to see if you can avoid or minimise your out-of-pocket costs.
Assisted reproductive services generally require medications as part of treatment. Depending on the drugs required, some of these costs may be covered by Medicare through the Pharmaceutical Benefits Scheme (PBS), and some may be covered by your health fund through an extras cover policy (i.e. non-PBS-listed medications).
Some health funds might not cover a prescribed medication if it’s underneath the PBS co-payment price, whether it’s listed on the PBS or not.
There are also other outpatient services that can’t be covered, such as consultations with fertility specialists, ultrasounds and blood tests. Some of these services may be claimable through Medicare subject to your doctor’s referral, while others will have to be paid from your own pocket.
You’ll be able to claim a Medicare rebate for some IVF costs too, provided your doctor has referred you for IVF or fertility treatment. You’ll likely still incur out-of-pocket expenses, but they’ll vary based on individual doctor’s fees, the type of assisted reproductive service you undergo and if you have health insurance.
You may also be eligible for the Medicare Safety Net, which can help you with some of these out-of-pocket costs.
Your treatment for an IVF cycle will usually include a series of consultations with an assisted reproductive specialist, blood tests, ultrasound scans and counselling – some of which may be claimed on Medicare subject to your doctor’s referral.
Keep in mind that Medicare will only offer benefits for MBS-listed assisted reproductive services where health professionals have deemed them clinically relevant. For example, Medicare will typically be available if your doctor has referred you for IVF or other reproductive services.1
Assisted reproductive services are medical treatments that help people conceive a child when other methods of conception aren’t working. People use these services for a variety of reasons, ranging from infertility to an inability to carry a child through pregnancy and even to avoid passing genetic issues on to children.
It’s not just couples or women who rely on assisted reproductive services, with procedures available to people of all genders, sexualities, ages and relationship statuses. People commonly use their private health insurance to help cover some of the costs for IVF and GIFT if they have an appropriate level of cover.2 Other types of assisted reproductive treatments may include:
Yes, anyone wishing to use assisted reproductive services through their relevant private health hospital policy will be subject to waiting periods. In most cases, services such as IVF and GIFT will incur a 12-month waiting period.
Infertility is typically classed as a pre-existing condition, and pre-existing conditions generally have a 12-month waiting period. Other pregnancy and birth related procedures are also subject to the 12-month waiting period. Similarly, you’ll have to serve a waiting period if you’re switching from a lower level of cover to a higher level that offers the reproductive service you’re seeking. If you switch to a policy with the same level of cover, you won’t have to re-serve waiting periods.
Talk to your doctor or IVF clinic before undergoing any procedures so you’re aware of what they charge, if Medicare will cover part of the cost, what this amount will be and how much you’ll be expected to pay yourself. You can also check this directly with Medicare through the MBS, where you can look up the item numbers for the treatments you want to see what their fee is. It is important to keep in mind that doctors can charge more than the MBS fee. In addition to this, the MBS fee does not include other potential costs such as accommodation. In cases where Medicare does provide benefits, there’s no maximum amount of treatment rounds per person.
If you wouldn’t be able to afford IVF or another assisted reproductive service on your own or through Medicare it might be worth considering an appropriate level of private health insurance. When you receive treatment through the private health system, not only could it be more affordable, but you’ll also have access to a private room and your choice of doctor (on availability)
If you’re interested in learning more about how private health insurance can assist with these costs, give our experts a call. They can chat with you about your healthcare needs and how a product like health insurance can help.
1 Australian Government: Services Australia – Medicare services for conceiving, pregnancy and birth. Last updated July 2022.
2 Commonwealth Ombudsman – Assisted Reproductive Services fact sheet. Accessed August 2022
