3. Are MAP procedures covered by the social security system? Yes
MAP is a medical therapy under Section 27a of Book V of the Social Code.
The medical services covered by the statutory health insurance also include medical interventions aimed to induce a pregnancy. MAP measures must be medically diagnosed as necessary and have reasonable chances of success.
The Statutory Health Insurance Modernisation Act [GKV-Modernisierungsgesetz] reasonably restricted the entitlement to MAP measures from 1 January 2004 onwards. Since then Section 27a of Book V of the Social Code specifies that 50% of the costs are covered by the health insurance fund, so that the insured equally share in the costs of MAP interventions with a co-payment of 50%.
To reduce the financial burden caused by the 2004 cutback in costs covered by the statutory health insurance fund, in 2012 the Federal Ministry for Family Affairs launched the federal initiative “Hilfe und Unterstützung bei ungewollter Kinderlosigkeit” (assistance and support for involuntary childlessness). The funds are paid from both the federal budget and the budget of the Länder in which the couples concerned have their principal residence. Currently, twelve of the sixteen Länder participate in the initiative. Federal funding is generally provided for the first four treatment cycles of in-vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI). Couples can be reimbursed up to 25 per cent of the share they have to pay in addition to the costs covered by the health insurance fund.
Until 2015, only married couples were entitled to additional federal financial assistance. Today, also unmarried couples living in a non-marital long-term relationship can receive federal financial assistance under the amended federal guidelines on financial assistance for assisted reproduction procedures (Richtlinie über die Gewährung von Zuwendungen zur Förderung von Maßnahmen der assistierten Reproduktion), which took effect on 7 January 2016. However, pursuant to Section 27a of Book V of the Social Code, entitlement to benefits from the statutory health insurance fund is still restricted to married couples only.
4. Are there specific criteria for such coverage? Yes.
The criteria included in Section 27a of Book V of the Social Code:
Coverage of part of the costs by the statutory health insurance funds is subject to the following requirements:
- the measures must be medically diagnosed as necessary
- according to medical diagnosis, the intervention must be reasonably likely to induce a pregnancy
- the procedure may be performed up to three times
- only married couples are eligible (non-married couples are not)
- only the spouses’ egg and sperm cells may be used (homologous system)
- prior to treatment, the spouses must have themselves thoroughly informed about the medical and psychosocial aspects involved by a physician other than the one who will perform the treatment
- MAP may only be performed by physicians or facilities that are suitably qualified and have obtained an appropriate licence from the authority responsible under the law of the federal Land
Any method other than homologous fertilisation is excluded from the mandatory package of benefits and services of the statutory health insurance system.
The restriction of eligibility to married couples is in accordance with the German Constitution (cf. Judgment of 28 February 2007 – 1 BvL 5/03, BVerfGE 117, 316).
Eligibility is subject to age limits of between 25 and 40 years for women and between 25 and 50 years for men.
Although unmarried heterosexual couples are not entitled to benefits from the statutory health insurance fund pursuant to Section 27a of Book V of the Social Code, they can receive the voluntary financial assistance offered through the federal initiative “Hilfe und Unterstützung bei ungewollter Kinderlosigkeit”.
5. Is the financial coverage limited to a number of MAP procedures? Yes. Pursuant to Section 27a of Book V of the Social Code three attempts to induce a pregnancy are partially covered by the health insurance funds. The payment of expenses by the health insurance funds has been limited to 50% of the costs approved along with the treatment schedule.