Medicare provides a rough division between the two arms of the heath service being hospital (inpatient) and medical (outpatient).  The responsibilities of Medicare and private health insurance can be roughly considered separated into two arms being private health insurance covering inpatient services and Medicare covering outpatient services. If patients don’t have private health insurance then the public health system covers the hospital treatment and this is covered by each state or territory.  Rebates from Medicare and private health insurance are not mutually exclusive and treatment may involve rebates from both which can cause confusion.

• A.  This is the first item in subgroup 3 which specifically covers ART and as the description indicates, is specially to cover an IVF procedure.
• B.  These are categorisation divisions.  The MBS categorises like services to aid the process of finding the correct item number to match the services provided.
• C.  The description concisely states what the service provides.  It also details any requirements, inclusions or exclusions.  In this case all laboratory services including blood tests, semen preparation and ultrasound measurements are included.  It also details the exclusions such as artificial insemination and transfer of frozen embryos which are covered by other item numbers.  It outlines a restriction on the service, namely that the treatment cycle is the first in the calendar year.  Any further treatments in a calendar year are covered by other item numbers.
• D.  The recommended fee and the benefit provided by the government in the form of a Medicare rebate are shown.  Note that the 85% benefit is not actually 85% of the scheduled fee, but is rather 97.4%.  This is not a mistake.  There is a maximum ‘gap’ defined in the schedule for out-patient services.  The gap is the amount between the rebate and the schedule fee. This gap is $83.40.  As 15% of the schedule fee, in this case $466.60, is greater than this gap, the maximum gap comes into play and the rebate is:    $3110.75 – $83.40  = $3027.35.   Note that there is no maximum gap for inpatient services and that the 75% benefit is actually 75% of the scheduled fee regardless of the gap amount.  However, it should also be noted that private health funds may cover the full 25% of the gap amount depending upon the policy (but not any amount above the schedule fee).
• E. Extended Medicare Safety Net (EMSN) Cap: The EMSN was introduced in 2001 to deal with non-gap out of pocket expenses which had increased dramatically due to the dramatic rise in the costs of providing medical services, introduction of new technology and a failure of the schedule fee to reflect the actual cost of providing the service.  The EMSN has a pre-determined threshold which is $2093.30 for 2018.  Prior to 2010, once the EMSN threshold amount had been reached Medicare would pay 80% of any further out of pocket expense between the scheduled fee and the fee charged by the medical professional for the service.  This quickly was discovered to be a stupid idea as it encouraged profiteering (medical professionals are human) and increased demand for unnecessary services by patients (they are also human).  Therefore in 2010 caps were provided on a number of high priced items including all ART services.  The cap for Item Number 13200 is $1675.00.  Once the out of pocket expense reaches $2093.75 ($2093.75 x 80% = $1675), then no further rebate is available.
• F.  This refers to the category notes which provide general information on the category, in this case Category 3: Therapeutic Procedures.  Para TN 1.4 refers to a more detailed description of a treatment cycle, in particular the deemed date of service (DOS).  Each item number must have a date of service associated with it to be eligible for rebate.  This is normally the date the service was provided.  For example, if a patient sees her doctor on Friday 1st March 2019, the DOS is 1/3/2019.  For those items that are provided over a longer period of time such as an IVF procedure there is a formula for deciding the DOS which is referred to as the deemed date of service.  For fertility services this formula is called the 30 day rule as it includes a service time of 30 days.
• For an IVF cycle the Date of Service (DOS) is the patient’s Day 1 as determined by either the onset of menses or the day the patient commences one of the FSH medications.  The time covered by the service usually ends 30 days later unless the day of the egg pickup or the embryo transfer occur after 30 days and then that date will be the end point.

The calculation of these rebates is not a simple exercise and for a better understanding we have provided a worked example in the Clinic Fees Example section of this website.

These items only cover some ART procedures, namely IVF and insemination procedures.  There is no provision for preliminary consultations or investigations, or follow-up consultations or treatments that do not involve IVF or inseminations, such as ovulation induction or ovulation tracking services.  Fees for any fertility service outside those explicitly described in the table below must be concocted from existing item numbers or billed with no accompanying item number.  A service without an accompanying item number is not eligible for Medicare rebates, nor is it included within the safety net or EMSN programs.  There is also considerable uncertainty regarding its stature for GST exemption.  Examples of these scenarios are given below:

1. Initial attendance with a fertility specialist:  In this situation Item Number 104 is adequate.  The scheduled fee is $85.55 and the 85% rebate is $72.75, however expect to pay in the vicinity of $400.00 as most initial appointments last 1 hour and involve both partners if applicable.
2. Ovulation induction: There is no specific item number covering this service but as it often involves blood tests and ultrasound measurements, which do involve specific item numbers, then these may be used by the clinic to cover the costs in providing the service, however in most cases expect fees ranging from as low as $150 to above $1000 for the cycle.  There is no Medicare rebate or safety net considerations with these costs.