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?
Is IVF covered by health insurance?
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.
Medications and outpatient services
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.
Does Medicare cover IVF?
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