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 does private health insurance play a role in reducing any out-of-pocket expenses?
Many turn to assisted reproductive technology such as In Vitro Fertilisation (IVF) or Gamete Intrafallopian Tube Transfer (GIFT). These procedures can be expensive, but part of their costs can be covered by health insurance. 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 the collection of eggs and transfer of embryos. Although the procedures take only hours and don’t require an overnight stay in the hospital, you’ll need to be admitted into a hospital or facility to undergo treatment.
As such, these services can be claimed on through private hospital policies; specifically, it’s available on gold hospital policies or as an additional benefit on a select few policies in lower tiers.
Assisted reproductive services generally require medications as part of treatment. Depending on the drugs required, some of these costs may be covered by Medicare and some may be covered by your health fund (i.e. non-PBS-listed medications). An extras policy may cover these costs.
Some health funds might not cover a prescribed medication if it’s underneath the PBS co-payment price – whether or not it’s listed on the PBS.
Check with your provider to ensure you’re covered for private hospital accommodation, operating costs, doctor fees and any other amounts charged by specialists involved in your treatment. Your private health fund may provide benefits towards these costs, but in cases where fees are charged higher than the Medicare Benefits Schedule (MBS) price (i.e. the fee the government sets and believes is appropriate for the procedure), you may still incur out-of-pocket expenses.
You’ll be able to claim some IVF costs through Medicare too – providing your doctor has referred you to IVF or fertility treatment. You’ll likely still incur out-of-pocket expenses, but they’ll vary based on individual doctor charges, 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 cycle for IVF will usually include a series of consultations with an assisted reproductive specialist, blood tests, ultrasound scans and counselling – all of which may be claimed on Medicare subject to your doctor’s referral.
Note that Medicare will only offer benefits for MBS-listed assisted reproductive services where health professionals have deemed them clinically relevant. For example, if your doctor has referred you for IVF or other reproductive services, Medicare will typically be available.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 relevant private health insurance to help cover some of the costs for In Vitro Fertilisation (IVF) and Gamete Intrafallopian Tube Transfer (GIFT), according to the Commonwealth Ombudsman.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 procedures are also subject to the 12-month waiting period. Similarly, you’ll have to sit out waiting periods 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, then you won’t have to re-serve waiting periods.
Talk to your doctor or IVF clinic before undergoing IVF so you’re aware of what they charge, if Medicare will cover part of the cost, and if so, what this amount will be and how much you’ll be expected to pay. You can also check this directly with Medicare using the MBS. In cases where Medicare does provide benefits, there’s no maximum amount of treatment rounds per person.
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 August 2019.
2 Commonwealth Ombudsman – Assisted Reproductive Services.