By Susan Hammerberg, Fertility Financial Expert
Health insurance coverage for fertility care, medication, and treatment can vary greatly depending on the plan and its benefits package. It can be confusing to navigate the world of insurance coverage, especially when it comes to fertility.
The first step is to review your insurance benefits policy and check to see what is covered. Some insurance providers may offer full coverage for all fertility treatments, while others may only cover certain procedures, and even others may offer no coverage at all. It’s important to note that even if your plan does cover fertility care, there may be restrictions or limitations on what is actually covered.
Make sure to review your individual health insurance plan and benefits carefully to understand what fertility care is covered and what costs you may be responsible for. This may include costs for deductibles, copayments, coinsurance, diagnostic testing, and medications, as well as procedures such as in vitro fertilization (IVF). If you are unsure about your coverage, it is best to contact your insurance provider directly. They can provide you with specific information about your plan and answer any questions you may have.
Below are some common insurance coverage terms and meanings:
- Deductible: amount you pay for covered health care services before your insurance carrier pays
- Copayment: a fixed amount you pay for a covered service (such as an infertility treatment in this case)
- Coinsurance: percentage of costs of a covered service you pay after your deductible
- Out-of-pocket maximum: the most you pay for covered services in a plan year
- Excluded services: health care services that are not covered
- Maximum limit: a cap on the benefits you may get from your insurance company in your lifetime
- Out-of-pockets: your self-funded expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services, plus all costs for services that aren’t covered
- Prior authorization: approval from a health plan that may be required before you fill a prescription or go through treatment so that it will be covered by your plan
- Referral: a written order from your primary care physician (PCP) or doctor of obstetrics and gynecology (OBGYN) for you to see a fertility specialist or reproductive endocrinologist (RE), or to receive certain medical services. If you don’t get a referral first, the plan may not pay for the services
Insurance for fertility
Keep in mind that some policies will have no coverage, meaning they will not cover testing or treatment, while others may only pay for testing or anything up to the diagnosis of infertility. Some will pay for testing plus certain procedures, while others may require you to do a certain number of intrauterine inseminations (IUIs) prior to any IVF procedures. Some policies will pay for assisted reproductive technology, including IVF coverage.
Some health insurance policies have a maximum benefit, and once that is met, you no longer have coverage. Some maximums are per year and reset each year, while others are called a “lifetime maximum” and will not reset. Once the maximum has been met, you no longer have coverage for fertility services for that policy term or your lifetime.
You may have fertility insurance coverage with an “in-network” physician as opposed to an “out-of-network” physician, and some plans only allow you to go to certain fertility specialists or clinics. These are sometimes referred to as “centers of excellence.” When your insurance states that the physician or clinic is out-of-network, you may have less coverage, or no coverage at all. If your physician is out-of-network and you have out-of-network coverage, it means you can have services rendered, but your deductible, out-of-pocket maximum, copayments, and coinsurance may be higher than your in-network benefits.
When verifying your coverage with your insurance provider, it helps to have current procedural terminology (CPT) codes, as well as diagnosis codes. You can obtain these from your clinic.
If your policy requires prior authorization, it is important to verify the authorization has been obtained and approved before ordering any medication or starting any treatment. If you proceed without this authorization in place, the services may not be covered, and you would then be financially responsible for those services. Unless you are financially prepared to pay out-of-pocket for those services, do not proceed without the prior authorization in place.
Anesthesia, which is sometimes used in certain fertility treatment options, is often provided by an outside company or individual whose services are contracted with your clinic. Be sure to check that they are in-network and covered by your insurance.
Medication for fertility will typically be ordered from a specialty pharmacy. You should always call your insurance to verify your pharmacy benefits. Some insurance companies and plans require you to use a certain pharmacy for cost savings and/or require prior authorization. If medications are not covered by your insurance, ask your nurse for a list of pharmacies that offer savings for self-pay patients. You may also want to call each pharmacy on the list to see who offers the best pricing for each medication, as costs can vary.
When undergoing fertility testing or treatment, you may encounter what are known as “elective services.” These may not be covered by insurance. It is always recommended you call your insurance to verify if each test or treatment is covered under your plan. If these services are recommended by your physician, inquire with your practice about the self-pay cost associated, if not a covered benefit. These services, if rendered, will not apply to your deductible or out-of-pocket maximum if they are a non-covered benefit.
Some of the elective services are:
- Preimplantation genetic testing (PGT): this refers to genetic testing done on embryos created during an IVF cycle before a transfer. There are 2 separate costs associated with PGT: the cost of an IVF cycle and the cost for the lab to conduct PGT on the embryos. These costs apply to each IVF cycle you wish to test
- Cryopreservation: this refers to the freezing of tissue (embryos, eggs [or oocytes], and/or sperm), as well as the tissue storage (continuing to keep the tissue stored or frozen)
- Donor egg, donor sperm, donor embryos: this refers to using the egg, sperm, or embryo of someone else
- Surrogacy or gestational surrogacy: this refers to someone else carrying the pregnancy
There are many more elective services that different physicians may order. It is always best to have conversations with your care team to find out why the service is recommended and what the costs are, and to speak to your insurance provider to find out if it is a covered benefit.
Most clinics have financial counselors who will verify your benefits and explain what your estimated costs will be, including what is covered and not covered. Ask for a copy of this verification, as they will more than likely have the CPT (procedure) codes and DX (diagnosis) codes listed, along with the response received by the insurance company. Again, you can verify this information by calling your insurance company directly.
There is usually a disclaimer from insurance companies stating that this is not a “guarantee of coverage,” and that the coverage amounts shown will remain unchanged until the date services are rendered. Any claim submitted is subject to all plan provisions, including eligibility requirements, exclusions, limitations, and state mandates (fertility insurance coverage laws). Coverage will be determined based on the facts existing when services are rendered. Basically, until the insurance provider receives the claim and processes it based on your benefit plan policy, they do not guarantee the claim will be paid.
Multiple insurance policies
If you have more than one insurance policy, even if the additional insurance policy has no fertility coverage benefits, you will need to provide all insurance information to your clinic. If you only provide one policy and later it was identified that you had other insurance, the insurance company that paid for services can recoup their payments because you had other insurance. Even if there is no covered benefit, the primary insurance needs to be billed first, and then the explanation of benefits (EOB) from your primary insurance will be sent, along with the claim, to your secondary insurance for processing.
When you have more than one insurance policy, you want to contact each of your insurance providers and let them know you have another insurance policy. This is called a “coordination of benefits (COB).” They will then determine which policy is primary and which one is secondary. More than likely your policy where you are the subscriber would be the primary, and the secondary would be the one where you are a dependent. If you have two policies that you are the subscriber on (for example, you work two jobs and have insurance through both employers), then usually the policy that was in effect first becomes the primary insurance plan, and the other would be secondary. It is always recommended that you call your insurance and inform them of additional policies and complete the coordination of benefits. If one of the policies terminates, you also want to call the remaining active insurance providers to let them know you no longer have that secondary policy, and to update the coordination of benefits.
When reviewing your clinic’s self-pay packages, look at the bigger picture of what provides the most cost savings when it comes to your family-planning goals. If they offer a package that allows more attempts at trying to conceive and saves you more money in the long run, it may be financially beneficial to purchase the more expensive package. Compare the packages to see what the cost difference is of purchasing the “multiple attempts” package as opposed to paying for a single attempt multiple times. Obtain in writing the refund policy of unused portions of the treatment packages. Some clinics will not allow you to upgrade to another package and will not apply what you previously purchased toward the upgrade.
It’s worth exploring all options for treatment and discussing them with your healthcare provider to determine the best course of action for your individual situation. Then, make sure to always call your insurance provider to fully understand what’s covered and what’s not. And remember, there may be other financial options to help you on your journey to parenthood.