Private health insurance for IVF and assisted reproductive services

Yes, it can be provided that you have the right policy and have served any applicable waiting periods, private health insurance covers some of the costs of inpatient medically necessary IVF treatment.

There are two main types of expenses associated with reproductive healthcare that private health insurance can help with: in-patient doctor and hospital fees, and non-PBS medication.

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 or fertility clinic. Or you may be able to use extras cover to pay some of the cost of non-PBS medication.

Day surgery will be required for treatment involving egg collection or frozen embryo transfer. Although the procedures only take hours and don’t require an overnight stay, you’ll need to be admitted to a hospital or facility to undergo treatment in order to claim a benefit from your health fund.

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 included 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 (the MBS is 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 medication 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.

Other outpatient services that can’t be covered by health insurance, such as consultations with fertility specialists, ultrasounds and blood tests may be claimable through Medicare subject to your doctor’s referral, while others will have to be paid by you.

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 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 a 12-month waiting period. Similarly, you’ll have to serve a waiting period for any upgrades to your policy. 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, how much Medicare will cover, 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 you’ll also have access to a private room and your choice of doctor (on availability).

You’ll be able to claim a Medicare rebate for some IVF costs, 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 an appropriate level of private health insurance.

If you have high medical costs, you may also be eligible for the Medicare Safety Net, which can help you with some of these out-of-pocket costs.

A fertility treatment like IVF is not a one-off procedure. A cycle of IVF could include a series of consultations with an assisted reproductive specialist, blood tests, ultrasound scans and counselling, plus the egg collection and implantation. Some of these may be claimed on private health insurance or 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. Medicare will typically be available if your doctor has referred you for IVF or other reproductive services.¹