Reimbursement by your health insurance
The costs of fertility treatment are high and can be around 3,000 to 5,000 euros per IVF treatment — even higher for ICSI. If you also take into account that many patients need several attempts before their wish for a child is fulfilled, they usually have to dig deep into their pockets.
An important question is whether the costs of assisted reproduction are covered by health insurance, and what conditions have to be met.
Assisted reproduction: reimbursement by your health insurance
Statutory health insurance
Important prerequisites for reimbursement by statutory health insurance companies
For people with statutory health insurance, the requirements for reimbursement of costs for fertility treatment are laid down in Social Code Book 5, more precisely in § 27a of the German Social Code Book V (SGB V).
These regulations are specified in the so-called “Guidelines on Artificial Fertilisation”.
Approval of fertility treatment by the health insurance fund
The most important prerequisite for reimbursement of the costs of assisted reproduction by the health insurance fund is that the treatment must have been approved by the health insurance fund before it begins. There are forms available at the fertility centre for this purpose. The personal data and the exact treatment costs are noted on the form. The form also indicates the amount that each couple has to pay for assisted reproduction.
In addition, the statutory health insurance requires the couple to be married to each other.
In order for the health insurance to cover the costs, the couple must be at least 25 years old. The age limit for assisted reproduction is 40 years for the woman, and the man must not be older than 50.
How much does the statutory health insurance cover?
The law stipulates in § 27a SGB V that the health insurance fund must agree to cover 50% of the costs of assisted reproduction. The couple must pay 50% of the treatment costs themselves. These costs start from around 1,300 euros for IVF and around 1,800 euros for ICSI.
How often can you try?
Furthermore, there is a fixed maximum number of treatments. In the case of assisted reproduction, the health insurance company will cover the costs for a maximum of three attempts at IVF or ICSI treatment and for a maximum of eight inseminations.
This regulation is related to the fact that, according to the ruling of the legislators, the probability of success for the occurrence of a pregnancy is too low if no pregnancy has occurred after the specified maximum number of treatment attempts.
In the case of a desire to have a child, a health insurance fund only has to reimburse those costs that are incurred for the treatment of its insurance member. For the man, these are usually sperm extraction and sperm preparation, and for the woman, all gynaecological treatments plus the costs of medication.
Also included here are the costs of assisted reproduction services that take place outside the insured person’s own body (so-called “extracorporeal services”). This includes laboratory services once the eggs are in the incubator and develop into embryos.
Possible exception — What can the health insurance fund do?
Some health insurance funds use their legal options under the GKV-Versorgungsstrukturgesetz (GKV-VStG) to deviate in their statutes from the regulations in § 27a SGB V and the guidelines. For example, some health insurance funds reimburse the costs for more than three attempts or do not require a co-payment.
In any case, it is worthwhile to contact your own health insurance company regarding the conditions for cost coverage and to seek advice. Each couple should decide for themselves individually whether a change of health insurance is an option for them during the period of infertility treatment.
Private health insurance
Regulation of cost coverage by private health insurance companies
The system is slightly different for privately insured persons. The regulations in § 27a SGB V are not decisive here, but only the insurance contract that the individual concludes with his or her health insurance. The general insurance conditions and tariff conditions regulate whether and which costs the health insurance will reimburse for assisted reproduction. These conditions should be checked carefully in advance to avoid misunderstandings.
It may be that the health insurance is not obliged to cover the costs of fertility treatment. It may also be that prior authorisation is required.
As a couple, you should check the claims arising from the insurance contract very carefully beforehand.
For privately insured persons, the so-called causation principle applies. This means that the health insurance company, among other conditions, only has to cover the costs if its insurance member “causes” the treatment, therefore the reason for the infertility lies with the insurance member. In this case, the treatment costs are reimbursed in full according to the tariff.
If the insurance member does not cause the assisted reproduction, the health insurance does not have to pay. However, this only applies if there is also a 15% chance of success.
This value was determined by a ruling from the Federal Supreme Court. It is based on several medical factors. The age of the woman, the number of eggs and the fertilisation of the eggs are important. It is also important whether a transfer has taken place.
As long as the aforementioned 15% chance of success is achieved, the number of medically necessary attempts at assisted reproduction is not limited.
For persons entitled to benefits, such as teachers, the regulations in the rules on benefits apply. These are based on § 27a SGB. This means that the legal requirements and restrictions for fertility treatment also apply.
Assumption of costs for assisted reproduction: Possible problems
Most problems with artificial insemination arise when:
— one partner has statutory health insurance and the other has private health insurance
— Both partners are not insured in the same private health insurance fund.
— or are also entitled to benefits.
Fundamentally different insurance systems clash on the subject of cost coverage and the possible claims are often opaque. Therefore, it can be advantageous to seek the advice of a specialist who can shed light on the jungle in the field of assisted reproduction.
Other common problems are the questions of causation and the chances of success of fertility treatment. Here, the so-called AMH value and the evaluation of the spermiogram are most important.
The costs of cryopreservation are generally not reimbursed because it is not an independent treatment. However, this does not apply at least if the reason is, for example, cancer treatment. This has recently been regulated in § 27a para. 4 SGB V.
At Fertilly, we have made it our mission to accompany couples (homosexual and heterosexual) and singles on the way to fulfilling their child wish. In doing so, it is important to us to create transparency in the area of fertility services, to provide information and knowledge on the topics of pregnancy and fertility and to help you to find the most suitable Fertility Center. Through cooperation with first-class Fertility Centres and clinics in Europe, enquiries about Fertilly are given preferential treatment. This means that our patients avoid the usually long waiting times and get appointments more quickly.
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