PMA: how are patients reimbursed by health insurance and mutual insurance companies?

PMA: how are patients reimbursed by health insurance and mutual insurance companies?

How does health insurance currently cover medically assisted procreation (PMA)?

MAP is 100% covered by Social Security under certain conditions :

  • Being a heterosexual woman and in a relationship.
  • Be under 43 years old.

Artificial insemination is covered up to one attempt per cycle, with a maximum of 6.

As for in vitro fertilization (IVF), it is covered for a maximum of 4 attempts. Additional attempts are therefore the responsibility of the couples. However, each successful pregnancy resets the care counter.

Do mutual insurance companies also intervene in the management of PMA?

If the Health Insurance covers 100% of PMA, it is only up to the conventional rate of Social Security. And, often, this conventional tariff does not correspond to the costs borne by the patients. For a more complete reimbursement, some complementary will take care of the overruns of fees (private clinics, gynecologists, imaging procedure, biological analyses, etc.), non-reimbursed drugs, the hospital package, etc.

Mutual funds can also take charge of “ non-reimbursed IVF ” (for example, beyond the age of 43 or the 4th attempt ) in the form of flat rates “Help with conception not covered by insurance disease “.

The number of refunds or the specific package will depend on the level of the contract taken out.

PMA: What does health insurance cover?

When a couple fails to naturally fulfill a desire for a child, they can resort to medically assisted procreation or PMA. In Switzerland, approximately 2,000 children are born each year thanks to assisted reproduction in the 30 authorized centers, ie 1 child in 40. To be able to use this practice, certain criteria must be met. MAP is only possible if it is used to remedy infertility for which there are no treatments or these have failed. A homosexual couple or a single woman cannot, therefore, use it. In addition to the eligibility criteria, the couple must also have the financial means to cover these very expensive medical treatments, which are not all covered by basic health insurance. So many reasons that push couples to practice PMA abroad. 

So, which treatments are covered by basic and complementary health insurance? Can we practice a PMA in Switzerland without breaking the bank? Decryption. 

PMA: what health insurance coverage? 

Basic health insurance offers coverage deemed insufficient for most couples using PMA. The vast majority of costs remain their responsibility. 

If the consultations, investigations, and analyzes are well reimbursed (subject to deduction of the deductible and participation costs), the reimbursement of ovarian stimulation with artificial insemination is limited to 3 cycles, most of the time insufficient to get pregnant. A single cycle of ovarian stimulation costs between 2,000 and 2,500 CHF. 

Regarding IVF or In Vitro Fertilization, it is currently not reimbursed by basic health insurance. For such a treatment, it will take between 10,000 and 15,000 CHF. 

In Switzerland, only homologous in vitro fertilization is permitted. IVF with eggs other than those of the recipient woman is prohibited, as is egg donation. Embryo donation and surrogacy are also illegal in the territory.

 According to the Federal Statistical Office, the use of medically assisted procreation has more than doubled in the space of 8 years (between 2002-2010) and continues to increase each year. In 2002, 1845 couples had started ART treatment compared to 4000 in 2010. There were 3896 in 2016. 

So, with growing demand from the population for these treatments against infertility in the couple, can we consider a reform of the basic health insurance on the cover of the PMA?

Towards a reimbursement of the PMA?

Insurers know it, requests for PMA are not weakening, quite the contrary!

However, basic health insurance cover is very limited and complimentary insurance does not cover such treatments. 

To meet the needs of the population, some insurance companies begin to wonder about possible coverage of this care. 

This is the case of the insurance company Sanitas, which has launched a proposal for complimentary cover for “the desire for children” to fill the gaps in the market. This cover funds assisted reproduction treatments, including IVF. up to 75% of the costs but with a ceiling of 12,000 francs (ie the cost of a single IVF). Coverage is limited to other conditions.

The reimbursement of the PMA by basic insurance is currently under discussion between the insurers and the Confederation.

 In addition to supplementary insurance, some health professionals and specialists in reproduction would like assisted reproduction treatments to be covered by basic insurance. 

Indeed, according to the WHO, infertility is a disease. So why does basic health insurance not cover this disease?

 

The fear of rising costs

The main concern of the State is to see health costs increase, particularly with multiple pregnancies due to IVF, which are becoming very costly in terms of premature births and neonatology in particular. 

To this, the supporters of the cover of the PMA by the compulsory health insurance, propose a reimbursement of the IVF limited to one embryo at a time. This is currently the case in other European countries such as 

By aamritri

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