Health insurance for endometriosis
Endometriosis affects 1 in 10 Australian women. Here's how it's covered by health insurance.
What different scores mean
9+
Excellent
These products offer a balance between low pricing and more features.
7+
Great
Competitive products within their group.
5+
Standard
Usually these products would either have fewer treatments covered or higher pricing.
0+
Basic
Offering basic cover with limited features or higher pricing.
Key takeaways
- Bronze hospital policies cover endometriosis treatment under gynaecology from about $21 weekly.
- As a private patient, Medicare pays 75% of the MBS fee and your hospital cover must pay at least the remaining 25%.
- With recurrence rates of 40-50% after five years, private cover can help manage ongoing costs.
Endometriosis is a condition that affects a woman's reproductive organs. Around 1 in 7 (14%) Australian women are diagnosed with endometriosis by their late 40s, and diagnosis takes an average of 6 to 8 years from when symptoms start. If left untreated, it can lead to infertility.
Fortunately, getting cover is easy and can be found on all Bronze policies if you choose to go private. This guide helps you look at both Medicare and private health insurance cover, so if you need help, you don't have to worry about large medical bills.
What is endometriosis?
Endometriosis is a condition in which tissue that normally lines the inside of your uterus grows outside the uterus.
During ovulation, the endometrium thickens. This means that displaced endometrial tissue continues to thicken, break down and bleed every menstrual cycle. However, it becomes trapped as it has no way to exit the body. As a result, fibrous scar tissue can develop over time on the lining inside the abdomen causing the uterus, ovaries, fallopian tubes and bowel to stick to each other.
Endometriosis can be very painful, particularly during menstruation and fertility problems can develop if the condition is left untreated.
Finder survey: How many Australians think hospital insurance is worth it?
| Response | |
|---|---|
| Somewhat | 38.17% |
| Yes | 34.89% |
| No | 26.94% |
Source: Finder survey by Pure Profile of 1006 Australians, December 2023
How does private health insurance cover endometriosis?
As of 1 April 2019, endometriosis is covered under all Bronze categories, thanks to government reforms. You will find cover for endometriosis under gynaecology. The changes are part of the government's attempt to make women's health care more widely available and affordable. You can find cover for around $21 a week with a Bronze policy.
Most private health insurers will cover surgery and theatre fees as well as things like medication you receive while in hospital and accommodation. It will cover you for any benefit that Medicare covers and you will also likely receive cover for any prescription medication you need.
Unlike Medicare, you also get to choose your own doctor and hospital. This can be important for many since endometriosis is such a difficult condition to diagnose.
If you do need surgery for endometriosis, you will likely know well in advance. This can be beneficial as it means you can calculate costs to keep them to a minimum. You can work out your estimate by doing the following:
- Speak to your gynaecologist and surgeon about cost estimates.
- Make sure your surgeon is part of your insurance provider's preferred list, if it has one.
- Inquire about extra costs. You may need to go under general anaesthesia.
- Check your policy's gap cover to help reduce or eliminate out-of-pocket expenses.
- Ask for your Medicare code and give it to your insurer.
How does Medicare cover endometriosis?
For surgical operations such as laparoscopic surgery, Medicare covers 75% of the fee listed in the Medicare Benefits Schedule (MBS) when you're admitted as a private patient. If you don't have hospital cover, you have to pay that remaining 25% – plus anything your surgeon charges above the MBS fee – out of your own pocket.
The fee listed on the Medicare Benefits Schedule for endometriosis-related surgery is $1,242.65, so the 25% Medicare doesn't pay works out to around $310. If you're admitted as a private patient and your policy covers gynaecology, your insurer has to pay at least that remaining 25%, and you're only out of pocket for anything your surgeon charges above the MBS fee. As a public patient in a public hospital you pay nothing for your treatment. Medicare will also pay benefits towards therapeutic procedures.
If you receive medication for endometriosis, there is a good chance it will not be listed under PBS medication, meaning it will not be subsidised by the Australian government, which may lead to large out-of-pocket expenses.
What are the symptoms of endometriosis?
Endometriosis is usually most painful when you have your period but for many women, the pain is there all the time. While the main symptom is pelvic pain, cramping is also common. It's common that pain will increase over time.
Common symptoms of endometriosis include:
- Painful periods
- Pain during sexual intercourse
- Pelvic pain
- Ovulation pain
- Pain in you lower back and thighs
- Pain with bowel movements or urination
- Reduced fertility
- Nausea, fatigue, diarrhoea or constipation
Although the extremity of your pain is a strong indication that something is wrong, you can still have advanced endometriosis with little pain, or mild endometriosis with a lot of pain. It can often be mistaken for pelvic inflammatory disease (PID) or ovarian cysts.
How do you diagnose endometriosis?
Diagnosis of endometriosis can be difficult. An internal pelvic examination is not usually successful so you may need to go to a gynaecologist. Diagnosis can include:
- Laparoscopy. This is a surgical procedure where a slim medical instrument with a camera is used to examine your pelvic organs for signs of endometriosis. It is performed under general anaesthetic.
- Ultrasound. This is usually done by pressing the ultrasound device against your abdomen.
- Colonoscopy. This is usually done if the endometriosis is affecting your bowel.
What does treatment for endometriosis involve?
Endometriosis doesn't have a known cure but is treatable with medication, hormone treatment or surgery. Often, you will need hormone therapy as well as surgery.
Medication
It's often the case that in mild cases, you may simply be prescribed anti-inflammatory medications such as Ponstan, Naprogesic or Nurofen to reduce swelling and pain. Most medications are included in the PBS but over-the-counter drugs like paracetamol are sometimes an effective solution for less severe cases.
Hormone treatment for endometriosis
Because endometriosis is exacerbated by the menstrual cycle, there are a range of hormone therapy options available that can help improve the condition. These include:
- Progestins
- Gonadotrophin-releasing hormone (GnRH) agonists
- Oral contraceptive pill
With any hormone treatment, it's important you're well informed about any side effects, so make sure you discuss it with your doctor well in advance.
Surgery for endometriosis
Surgery for endometriosis is also common. Options can include:
- Laparoscopic surgery: The most common surgery. A slim tube called a laparoscope, which has a camera on the end of it, is inserted into the abdominal cavity with a small incision and any adhesions and irregular tissue associated with endometriosis are removed.
- Laparotomy surgery: This is complex surgery that is usually done when laparoscopy surgery will not adequately resolve the issue.
- Hysterectomy: This is an option if other treatment has not worked and endometriosis is having a severe impact on your quality and standard of life.
- Bowel surgery: This is usually required if endometriosis has developed in your bowel.
What is surgery recovery time?
Depending on the severity of your condition, laparoscopic surgery takes from 30 minutes to 6 hours. You can usually go home after laparoscopic surgery but you may need to stay overnight in hospital if you have pre-existing health conditions or have severe endometriosis.
Other surgeries, such as laparotomy surgery, will always require an overnight stay, though it's usually longer. It can take between two and six weeks to get back to normal and daily tasks around the house can be difficult for the first few weeks.
What do you have to be careful with when claiming for endometriosis?
It's vital you make sure you know exactly what you're covered for. It is sometimes the case that you won't be covered for surgeon's fees. This can include the operating theatre costs, time spent on surgery, any complications that may arise from the surgery and more. Be careful as some insurers will claim they cover endometriosis-related procedures but will only cover specific item numbers. This is why you should check to find out exactly what's covered before taking out a policy.
What is covered with each tier?
While some may only be looking for cover for endometriosis, which can be found with a Bronze policy, it's worth remembering this doesn't include pregnancy or fertility-related services. For many suffering from endometriosis, infertility can become an issue. If this is the case, you might want to consider Gold level cover which includes birth and pregnancy as well assisted reproductive services such as in-vitro fertilisation (IVF).
How much can I expect to pay for private health insurance?
Here is a small breakdown from Finder partners to give you an idea of how much you can expect to pay. Prices quoted are based on a single policy for a person living in Sydney, earning less than $105,000.
Finder Score - Hospital cover health insurance
Each month we analyse our hospital insurance products and rate each one on price and features. What we end up with is a nice round number out of 10 that helps you compare hospital cover a bit faster.
Before we start scoring, we need to make sure we're comparing like-for-like. Just as it doesn't make sense to compare a bicycle with a Ferrari, it doesn't make sense to compare basic hospital policies to top-tier Gold policies. Each policy is given a price score and feature score. These are then combined to determine each policies's Finder Score.
Pros and cons of treatments
Here are some things worth considering when looking at what treatment for endometriosis suits you best.
| Pros | Cons | |
|---|---|---|
| Over-the-counter drugs |
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| Steroid medications |
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| The contraceptive pill |
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| Laparoscopy |
|
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| Hysterectomy |
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What are the success rates like for treatment?
The likelihood of endometriosis recurring after surgery is around 20% at 2 years and between 40% and 50% at 5 years. Because it can be an issue that is likely to recur even after surgery, it's a good idea to consider private health insurance to keep costs down.
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