Figuring out your insurance coverage for diagnosing and treating fertility challenges is complicated. It’s easy to feel overwhelmed—what to do first, where to look, what to look for, and so on.
Our 4-point checklist for determining insurance coverage is an excellent place to start.
Get a copy of your evidence of coverage or certificate of insurance.
You probably have a copy of the summary of benefits for your health insurance plan, but that may not be sufficient to find the information you will need to determine what your policy covers for fertility. You can ask for a full copy of your evidence of coverage from your employer’s human resources (HR) department or by calling your insurance company. If you already have a copy of this document, make sure it’s the latest version because they change frequently.
Look for the sections within your insurance policy that address coverage, exclusions, and medication.
Frustratingly, each insurance carrier and each insurance policy is a little different, so there is no single place you can look to find your coverage for fertility. Usually, you’ll find what is covered under the sections on coverage; however, you should also specifically check the portion of your policy that lists what’s excluded. In both parts, look for words like fertility, infertility, in vitro fertilization (IVF), intrauterine insemination (IUI), artificial insemination, genetic screening, genetic testing, and semen analysis. Read carefully to see if limits exist. Those might include, but might not be limited to, the patient’s age, the number of IVF cycles covered, or the required order of treatment (for example, a certain number of IUIs before IVF will be covered).
It’s also a good idea to check and see if telehealth appointments are covered by your insurance policy.
In addition, check the section detailing your medication coverage. It might also be called prescription coverage. Look for what the policy says about medications needed for fertility treatment coverage. Are only certain drugs covered? Does this policy require that you use a specific pharmacy?
Ask for help.
Insurance policies can be confusing (that might be the understatement of the year!), and even the most educated among us could use the help. There are three main places to ask for help in understanding your insurance coverage for fertility: your employer’s HR department, your fertility clinic, or the insurance company itself. Most employers, depending on size, have someone designated in HR to answer questions about employee benefits. Most fertility clinics, also depending on the size of the clinic, will have someone on staff who is knowledgeable about insurance coverage. While both your employer and your fertility clinic can be helpful, remember that ultimately, it is your responsibility to understand your coverage. And don’t forget to check if your state mandates some coverage for fertility treatment.
Of course, your insurance company will be the best resource for understanding their policy. When calling your insurance carrier, ask to speak with someone in member services. Have your policy number and employee number ready.
When speaking with an insurance representative, take notes and make sure to include the date and the name of the person with whom you spoke. Follow up and get any important information on coverage in writing from the insurance company.
Get a letter of predetermination of benefits.
Before you start fertility treatment, ask your insurance company to send you a letter of predetermination of benefits. (It may have a slightly different title, depending on your insurance carrier.) Your fertility clinic may ask for this letter on your behalf, but you should have a copy for your records as well.
Don’t be intimidated by your insurance policy. Make a list of what you need to do to determine your insurance coverage for fertility and start checking it off to get one step closer to having the family you want.