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New item structure for Assisted Reproductive Technologies

What is the new item structure for Assisted Reproductive Technologies?

As foreshadowed in the 2009-2010 Budget, the Medicare items for Assisted Reproductive Technology (ART) services, including In-Vitro Fertilisation (IVF), have been restructured in negotiation with the ART profession and patient group ACCESS. The new structure better reflects current clinical practice and will be of benefit to patients as the base MBS rebates have been increased for a typical treatment cycle. In some cases, patients will receive an increased base MBS rebate which is significantly higher across a typical treatment cycle. More information about the new ART structure is provided below.

Will there be limits on access to ART services- such as limits on the number of cycles or age restrictions?

There will be no restriction placed on the number of cycles that patients can have under Medicare. Nor will there be any age restrictions placed on ART services.

Item number	Description	MBS Schedule Fee (1 Jan 2010) ($)	A: MBS benefit (1 Jan 2010) (out of hospital) ($)	B: EMSN Cap (1 Jan 2010) ($)	Maximum Medicare benefit payable per claim out of hospital (A+B) ($) #
13200	ART services - superovulated treatment cycle proceeding to oocyte retrieval – initial cycle in a calendar year	2,940.00	2,870.90	1,550.00	4,420.90
13201	ART services- superovulated treatment cycle proceeding to oocyte retrieval – subsequent cycle in a calendar year	2,750.00	2,680.90	2,250.00	4,930.90
13202	ART services – superovulated cycles that is cancelled prior to oocyte retrieval	440.00	374.00	60.00	434.00
13203	Ovulation monitoring services for artificial insemination	460.00	391.00	100.00	491.00
13206	ART services - natural treatment cycle or treatment cycle where oocyte growth and development is induced using oral medication only	440.00	374.00	60.00	434.00
13209	Planning and management of an ART treatment cycle	80.00	68.00	10.00	78.00
13212	Oocyte retrieval	335.00	284.75	65.00	349.75
13215	Transfer of embryos to the female reproductive system	105.00	89.25	45.00	134.25
13218	Preparation of frozen or donated embryos	750.00	680.90	650.00	1,330.90
13221	Preparation of semen for artificial insemination	48.00	40.80	20.00	60.80
13251	Intracytoplasmic sperm injection	395.00	335.75	100.00	435.75

New structure for the Medicare items for ART services from 1 January 2010

# Note: Actual rebate payable depends on the amount of out-of-pocket cost that a patient needs to reach the EMSN threshold and the fee charged by the doctor.

What are the EMSN caps?

From 1 January 2010, an upper limit will be placed on the amount of benefit that can be paid under EMSN for all ART Medicare services. The upper limit of the EMSN benefit (called the EMSN benefit cap) payable for ART services is listed in the table above.

The Medicare ART items were identified in the Extended Medicare Safety Net Review Report 2009 (the Review report) as areas of concern. The Review report found between 2003 and 2008 the fees charged for ART services fell by 9% for in-hospital services, whilst the fees charged for out-of-hospital services increased by 62%. This indicates that some doctors are structuring their billing to take advantage of the EMSN, as the fees charged for out-of-hospital services increased far in excess of the fees charged for in-hospital services.

The Review report also found that for some Medicare services with high out-of-pocket costs, such as some ART services, for every EMSN dollar, 78 cents was spent on meeting doctors’ higher fees, rather than reducing patients’ out-of-pocket costs.

The EMSN benefit is intended to be a patient benefit. It is not intended to be a mechanism for doctors to increase their fees.

How will the EMSN benefit caps work in practice?

The EMSN benefit cap will be applied at the item level. This means that the same level of EMSN benefit cap will apply to all claims for that item, regardless of the fee charged by the doctor.

All patients are eligible to receive up to the EMSN benefit cap, each time that they have a claim for the service.

Under the changes the method for determining the EMSN benefit will be the same, that is, 80% of the patient’s out-of-pocket cost once the patient has reached the EMSN threshold. If this amount is greater than the EMSN benefit cap, then the patient receives the EMSN benefit cap amount. If the calculated benefit is less than the EMSN benefit cap, then the patient receives the calculated benefit (which is equal to 80% of the out-of-pocket costs for the claim).

How will I be affected?

You will still receive the standard Medicare rebate for the services. You will still be eligible to receive EMSN benefits for all out-of-hospital Medicare services once you reach the EMSN threshold. The only thing that is changing is that there will be a maximum limit placed on the amount that you will get back through the EMSN for the ART items from 1 January 2010.