As­sisted re­pro­duc­tion: reim­bur­se­ment by your 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.

Mar­riage

In ad­di­tion, the sta­tu­tory he­alth insu­rance re­quires the couple to be mar­ried to each other.

Age

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.

Other

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.

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.

Cau­sa­tion prin­ciple

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.

Aid

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.

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.

> Fi­nan­cial sup­port for the de­sire to have children from the state and the Länder

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.

If you would like more in­for­ma­tion about Fer­ti­lity Cen­ters, suc­cess rates and prices, please contact us using this ques­ti­on­n­aire. We will ad­vise you free of charge and wi­t­hout any ob­li­ga­tion.