Trying for a Baby? Compare Health Cover for Fertility Treatment
For couples trying to conceive, working through issues of infertility can be frustrating, stressful, and heartbreaking. It is easy for these couples to feel isolated in their fertility struggles, but they are not alone – as many as 1 in 6 Australian couples have difficulty getting pregnant.
In addition to physical and emotional stressors that come with trying to convince, couples may also face financial hardship if fertility treatments or counseling is required.
Because the causes of infertility can vary greatly, the treatments are also wide ranging. While it is important for couples to understand their options for fertility treatments, it is just as important for them to understand the insurance options surrounding those treatments.
- Medicare can cover many of the fees associated with fertility treatments, but can still leave patients with bills of at least $2,000 per treatment.
- Adequate Private Health Insurance covers many of the costs that Medicare doesn’t. It can save a patient thousands of dollars on fertility treatments.
- Most Private Health insurers have a 12 month waiting period for new enrollees who are looking to make a claim for fertility treatments.
Medicare for Fertility Treatments
Medicare does offer some benefits to help couples pay for fertility treatments.
Most of these benefits come in the form of rebates for certain treatments. However, Medicare rebates may not apply to all treatments a couple wants or requires. Also, rebates may not cover the entire portion of treatments that Medicare does recognise. Therefore, patients could still be left paying for some or all of their fertility treatments under the Medicare rebate system.
Still, some patients may be eligible for additional fertility benefits under the Medicare Safety Net.
Medicare Safety Net
The Medicare Safety Net provides additional rebates to individuals and families who reach a certain threshold in a given year. The rebates do not apply to all medical costs, but could cover additional costs for certain out-of-hospital fertility treatments.
The Medicare Safety Net thresholds for 2018 are outlined in the chart below:
|Threshold||Threshold amount||Who it’s for||How it’s calculated||What the benefit is|
|Original||$461.30||All Medicare cardholders||Based on gap amount||100% of schedule fee for out of hospital services|
|Extended Medicare Safety Net (EMSN) Concessional and FTB Part A||$668.10||Concession cardholders and families eligible for FTB Part A||Out of pocket costs||80% of out of pocket costs or the EMSN benefit caps for out of hospital services|
|Extended general||$2093.30||All Medicare cardholders||Out of pocket costs||80% of out of pocket costs or the EMSN benefit caps for out of hospital services|
While singles are automatically enrolled in the Medicare Safety Net program, families and couples must register in order to receive benefits under the initiative. Families can register in one of two ways:
Fill out the registration form [insert hyperlink: https://www.humanservices.gov.au/individuals/forms/ms016]
Contact the Medicare General Enquiries line at: 132 011
Pharmacy Benefits Scheme (PBS)
Under the PBS, the Australian Government subsidises the cost of some prescription medicines.
All Australian residents who hold a current Medicare card are eligible for the Pharmacy Benefits Scheme and can receive benefits for some fertility treatment related medications.
PBS also has a Safety Net threshold program that will reduce the co-payment of medications once the threshold is met. Families registered under the same Medicare card can combine their PBS amounts to reach the Safety Net threshold sooner.
A list of subsidised medicines covered under the PBS is available online and updated monthly. Patients can find it here [insert hyperlink for https://www.pbs.gov.au/browse/medicine-listing]
What Isn’t Covered?
While Medicare will provide some financial assistance for various fertility treatments, there are several items that the public system does not recognise and will not reimburse.
Those items include:
- Hospital/day surgery related services, such as egg collections
- Procedures without a Medicare item number, such as testicular biopsy
- Some fertility treatment drugs
- Some cycle monitoring
Those who opt to use only Medicare for fertility treatment should prepare for potential out of pocket expenses.
The following charts estimate the costs a couple can expect when using Medicare alone for fertility treatments.
|Treatment Costs correct at 1 April 2017||Cycle payment||Estimated out of pocket costs 1st cycle in a calendar year (safety net not reached)||Estimated out of pocket costs subsequent cycles in a calendar year (safety net reached)|
|Frozen embryo transfer (FET)||$3,540||$2,237||$2,042|
|Intrauterine Insemination (IUI)||$2,430||$1,901||$1,760|
|Ovulation Induction (OI)||$700||$700||$700|
|Embryo freeze||$550 (includes 6mths storage)||Nil|
|Sperm freeze||$450 (includes 6 mths storage)||Nil|
|Surgical sperm collection – transcutaneous||$675||Yes|
|Surgical sperm collection – open||$850||Yes|
In addition to costs for standard medical treatments, patients should also be prepared to spend about $200 additional for drug treatments.
All told, couples that rely solely on Medicare should expect at least $2,000 in out-of-pocket expenses for each cycle if their treatment plan requires in vitro fertilization, or IVF.
When considering the potential for mounting costs of fertility treatments, it is important for patients to review all insurance options.
Private Health Funds and Fertility Treatment
For those considering or planning fertility treatments or consultations, Private Health Insurance could be a viable option. Many private health funds include coverage for fertility treatments that can save patients additional money when used with other benefits. Often, insurance companies include coverage for fertility treatments at various levels.
Those who combine private health coverage with Medicare benefits can expect to save at least an additional 13% on their out of pocket expenses over some who only use the public system.
Because each company provides different benefits, packages, and premium costs – it is important to evaluate them individually. In doing so, potential customers should make sure that plans cover the treatment options that are most attractive to them.
Potential customers should consider which plans cover various fertility treatments.
Common fertility treatments, or Assisted Reproductive Technologies (ARTs), include:
- In Vitro Fertilisation (IVF)
- Gamete Intra Fallopian Transfer (GIFT)
- Zygote Intra Fallopian Transfer (ZIFT)
- Intracytoplasmic Sperm Injection (ICSI)
- Embryo Replacement
- Blastocyst Culture
These treatments often involve many steps and can take place over an extended period of time. Some of the costs associated with ARTs include:
- Procedure cost
- Ultrasound cost
- Laboratory fees
- Hospital bed fees
- Specialist fees
- Anaesthetist fee
- Medication cost
- Nurse fees
In addition to considering which treatments are included with private coverage, patients should consider potential wait times associated with getting benefits after enrolling.
The following chart lists private health insurers that cover fertility treatments, the plans that include the treatments, and their benefits waiting period for infertility treatments.
|Health fund||Plan Requirement||Waiting periods||Notes|
|Latrobe||12 months||Waiting period could be waived if infertility is recognised as a preexisting condition|
|Mildura Health Fund||
||12 months||9 Months of waiting period can be served while pregnant|
|Queensland Country Health Fund||
|Peoplecare Health Fund||
|St. Lukes Health||
||12 Months||24 month waiting period if you are uninsured before obtaining coverage|
*as of May 2018
While private health insurance will help reduce costs by covering items not included by Medicare, it may not cover all costs associated with infertility treatments.
Private health insurance policies will often not include:
- Pathology services
- Some diagnostic procedures
- Egg transportation costs
Deciding to undergo fertility treatment is a big decision and can come with emotional and physical stress. While some of the pressure associated with trying to have a baby is unavoidable, figuring out how to pay for it isn’t.
Consider whether private health insurance is right for you in treating infertility, and if so, which plans best meet your family planning goals.
It is important to note that most insurers have a 12-month waiting period on fertility benefits, so you should plan early to take advantage of fertility treatment benefits.
Disclaimer: The above information is correct and current at the time of publication
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