The financial side of fertility treatment is fraught for many patients, and figuring out how to fund your care is challenging. Often, the last thing you want to think about are the intricacies and bureaucracies of insurance, but understanding your rights and your options can make a huge difference as you move forward. To help you get a clear picture of what you need and can expect from your insurance provider, we have put together this clear guide. Asking the right questions is the first step towards getting the right answers.
Does insurance cover infertility treatments?
This is the first question most people ask, and the answer is not a simple yes or no. Largely it will depend on which state you are living in. Currently, there are 15 states with legislation regarding required insurance coverage for infertility treatments. These laws fall into two categories:
- Mandate to cover: Arkansas, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, and West Virginia all have laws that require health insurance companies to include coverage of infertility treatment as a benefit in every policy. The policy premiums will include the cost of cost of infertility treatment coverage.
- Mandate to offer: California and Texas have laws requiring that health insurance companies offer a policy which offers coverage of infertility treatment. However, the law does not require employers to pay for the infertility treatment coverage, so if you are in one of these states you’ll need to find out whether your employer opted in to this coverage.
In general, even if you are in a state that requires coverage or the offer of coverage, there are a couple of exceptions:
- Self-insured plans are exempt from state law, so you will need to find out whether your employer is fully insured or self-insured.
- Employers with fewer than a set number of employees do not have to provide health insurance at all, so small family firms or startups may not offer coverage.
What are the specifics of the California mandate to offer law?
In California, the relevant legislation is located in the California Health & Safety Code, Section 1374.55 and the California Insurance Code Section 10119.6.
The law requires group insurers to offer coverage of infertility treatment, although this requirement excludes IVF. Employers may choose for themselves whether or not to include infertility coverage as part of their employee health benefit package.
“Infertility” is defined in the law as either:
- The presence of a demonstrated condition recognized by a physicians and surgeons as a cause of infertility; or
- The inability to conceive a pregnancy or carry a pregnancy to a live birth after a year or more of regular sexual relations without contraception.
The law defines “infertility treatment” as including:
- Diagnosis
- Diagnostic testing
- Medication
- Surgery
- Gamete Intrafallopian Transfer (GIFT)
There are some exceptions to the California mandate to offer law:
- As mentioned, it only requires the insurers to offer coverage, and employers do not have to purchase that coverage.
- IVF, one of the most popular and effective Assisted Reproductive Technologies (ART) is not included, though some insurance companies offer IVF coverage anyway.
- The law also does not require religion organizations to offer coverage for fertility treatments.
- Employers who self-insure are exempt from the requirements of the law.
Whom should I speak to regarding insurance coverage?
- Your first stop should be your employee benefits office within the HR department. Someone there should be able to walk you through the options.
- You can also call your health plan’s member services department.
- Your fertility clinic’s insurance coordinator may be able to help you, so don’t be afraid to ask, though out of network or new patients should probably talk directly to their employer or the insurance company first.
What information do I need before contacting my insurance company or employer?
Many people find these types of phone calls and meetings stressful at the best of times, and when you are dealing with something as important and potentially life-changing as fertility treatment, the pressure can go through the roof. Having all of your details together ahead of time can help to smooth the way.
Here is a checklist of the information to have at hand:
- Name of the insured person
- Employee/Patient ID number or SSN
- Employer name
- Insurance plan name
- Group code/number
- Patient’s name and DOB
What questions should I ask my employer regarding infertility coverage?
When you speak to HR, do not be afraid to press them for specifics. They should be able to answer the following:
- Does my current health plan cover infertility treatments? If so, is the coverage guaranteed renewable: i.e., will it be the same next year?
- If my current plan does not cover treatment, is there another health plan available that provides benefits for infertility diagnosis and treatments? What is the difference in cost between the two plans? How and when can I change plans: when is open enrollment and what qualifying events trigger a special enrollment period?
- Does my health plan have any restrictions or limits to the benefits they pay for infertility diagnosis and infertility treatments? If so, what are they?
- Is there any required waiting period before I can start infertility treatment for pre-existing conditions? If so, how long is it, and when does it begin?
What questions should I ask my insurance company regarding infertility coverage?
Once you get the basics from HR, you should be armed to dive into greater detail with a representative from your health plan. Be prepared to insist on clear answers to your specific questions, such as:
- What are the specific infertility benefits in my plan?
- Will I have to meet a deductible before coverage begins? If so, how much?
- After I have met my deductible, what level or percentage of coverage will be applied to covered treatments?
- Does my plan have out-of-network benefits? If so, what is my reimbursement percentage?
- How do I submit superbills for reimbursement of out-of-network procedures?
- Are the coverage levels the same for participating and non-participating providers? If not, what is the difference?
- Will my coverage be based on the allowable amount or the actual billed amount?
- Is there a maximum payment cap on infertility treatment coverage or on specific procedures?
- What, if anything, is excluded from coverage?
- Is preauthorization necessary for procedures? If so, which ones? How does the process work and what are the timelines?
- Will I need to get referrals from my GP? When and for which appointments?
- Are there age limits for infertility treatment? If so, what are they?
- What procedures and tests do the benefits cover for infertility diagnosis? Will I (and my partner) be covered for any or all of the following lab and blood work?
- Progesterone and estrogen levels, FSH/LH/TSH/and prolactin levels
- Semen analysis
- Ultrasounds
- Endometrial biopsy
- Post-coital test
- HSG
- What procedures and tests do the benefits cover for infertility treatment? Will I be covered for any or all of the following?
- Intrauterine Insemination (IUI)
- Gamete Intrafallopian Transfer (GIFT)
- Zygote Intrafallopian Transfer (ZIFT)
- In Vitro Fertilization (IVF)
- Intracytoplasmic Sperm Injection (ICSI)
- If I am not covered for a specific procedure, do I have coverage for the associated diagnostic and treatment lab work and tests, such as blood work and ultrasounds used to monitor the process of a cycle?
- Am I required to try certain treatments (such as IUI) before moving onto more intensive options (such as IVF)?
- If I am covered for IVF, how many cycles are included in my coverage?
- Does my plan cover the cost of fertility drugs? If not, is the cost of any fertility drugs reimbursable? Do I have to use a specific pharmacy or can I use a mail order option?
- Does my plan cover any genetic testing, such as Preimplantation Genetic Screening (PGS) or Preimplantation Genetic Diagnosis (PGD)?
- Does my plan cover donor egg treatment for the recipient? Will it cover the expenses for the donor?
- Does my plan cover cryopreservation for the storage of frozen embryos or eggs? If so, for how long?
- Which hospitals are affiliated with my plan? What are my out of network options?
- Can you offer me physician or clinic profiles or comparative data as I choose my provider?
- What is the notification process if coverage of a treatment is denied, reduced or terminated? Is there an appeals process? If so, what is it?
- Whom should I speak to if I have questions or problems?
How can I be sure I’m getting the whole picture?
Being an advocate for yourself and your health care can be overwhelming, but remember, you are the customer, and you deserve respect and clear communication from your insurer. As you investigate your options, there are a few things you can do to ensure that you are getting full and accurate information:
- Ask for a copy of your plan in writing. Going through with a highlighter and making notes will help you get clear on what is and is not covered, and may raise more questions for you to discuss with your insurer.
- Whenever you speak to someone on the phone, get their name. Sometimes representatives will offer conflicting information, and keeping track of who said what may become important. You can verify the answers you get by cross referencing between your HR representative and one or more health plan representatives.
What if I’m not covered?
If you don’t have coverage with your employer, it may be worth asking whether they would consider offering it: you may be pleasantly surprised. If you are self-employed or buy your own insurance, very careful shopping around for the right policy may open new doors to treatment. It’s important to remember that there are other choices out there, even if coverage is not available. IVF financing is an option, and may be more accessible than you think.
While finding your way through the insurance system is a challenge, the fact is that coverage can make a huge difference for many patients who are hoping for a baby. Fighting through all the red tape and paperwork is so worth it.
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