Following intense lobbying by key role players, the largest medical aid scheme in South Africa has introduced limited infertility treatment benefits on two of its plans.
Here’s all you need to know about assisted reproductive therapy (ART), why it has taken so long for schemes to introduce benefits and how Discovery Health covers the costs of treating infertility in 2021.
What is assisted reproductive therapy?
ART is used to treat infertility. It has a reasonably high success rate and consists of three core treatments :
- in-vitro fertilisation (IVF)
- artificial insemination
- hormonal stimulation of ovulation.
Although the techniques differ, IVF and artificial insemination involve removing eggs from the woman’s body, mixing them with sperm to form embryos and inserting the viable embryos into the woman’s body.
Donor eggs, donor sperm and previously frozen embryos can be used when there’s a problem with the viability of existing reproductive cells. On occasion, ART involves a surrogate who carries the baby to full term.
The artificial stimulation of ovulation, using hormones or fertility drugs, is used in conjunction with the precise timing of intercourse to achieve pregnancy.
How much does ART cost?
The estimated costs of ART interventions are high. A single cycle of IVF can cost from R60,000 to R100,000.
As more than one treatment cycle is typically required to achieve pregnancy, the end cost can be anything from R120,000 to R300,000 or more.
Up until recently, medical aid schemes in South Africa only covered the costs associated with the diagnosis of infertility. Couples had to pay for infertility treatments from their own pockets.
Now, members of Discovery Health’s elite plans are covered by a limited ART benefit, providing they meet the scheme’s clinical criteria.
Why it took so long for medical schemes to cover ART
Despite infertility being classified as a Prescribed Minimum Benefit (PMB) condition, medical aid schemes used a loophole in the classification to exclude infertility treatment from cover. The vast majority of schemes in South Africa still do.
According to the PMB classification code 902m, only the medical and surgical management of the infertility diagnosis has to be covered by all schemes.
As a result, procedures and interventions, like scopes, semen analysis, blood tests and certain surgeries, are paid from the PMB benefit. That is where the cover stops – unless you belong to one of two Discovery Health plans.
Associations, including the South African Society of Reproductive Medicine and Genealogical Endoscopy (SASREG), picked up the baton more than a decade ago. They’re actively negotiating with all medical aid schemes to provide cover for infertility treatment.
Their view is the neglect of the burgeoning number of scheme members battling with infertility is unfair discrimination. To date, only Discovery Health has come on board, as is evident from the 2021 roll out of limited ART benefits.
How Discovery Health covers ART
Discovery Health has included dedicated ART benefits in its Comprehensive and Executive options. Cover is limited to R110,000 per person per year. Members are liable for a 25% co-payment.
Only women aged between 25 and 42 years are eligible for the benefits. A woman must have been a member of one of two elite plans for at least two years. The scheme covers the cost of up to two treatment cycles per year, according to a defined basket of care.
Procedures and interventions covered by the ART benefit include infertility consultations and medicines, egg retrieval, embryo transfers and freezing, embryo and sperm storage, ultrasound scans, admission costs and lab fees.
Qualifying members have to use SASREG-accredited network facilities. Any additional treatment not included in the basket of care is paid for from the member’s available day-to-day benefits, medical savings or PMB benefits.
IFC
At IFC, we offer informed, objective advice about medical aid cover for assisted reproductive therapy, and can assist you in joining the scheme that best suits your needs and budget. Contact us for more information or to discuss your needs.
