Fertility insurance coverage can often be complicated to navigate. But getting the hang of its vocabulary can make the process a little bit easier. As you gather the information you need to find out what, and how much, fertility treatment your insurance covers, you may come across these phrases.
Insurance plan (or policy)
This is the agreement between you and a health insurance provider in which you pay a fixed cost each year to the insurance company, which then covers various medical expenses. You can find out which medical expenses your plan covers, and how much, by reviewing the “Summary Plan Description.” If you don’t have it already, you can ask your HR representative or insurance provider for a copy.
These are the medical treatments and procedures that are covered in full or in part by your insurance plan. Your plan will pay for some or all of the medical treatments or procedures listed as covered services. You have to pay for any uncovered service that you receive.
Medical necessity vs medical benefit
A medical necessity is medical care that your doctor classifies as necessary; it may or may not be covered by your insurance plan. A medical benefit is something your insurance plan covers. Fertility treatment is not always considered a medical necessity.
State mandate to cover
Mandate to cover means that some or all insurance providers administering plans in these states are legally required to cover certain fertility treatments.
State mandate to offer
Mandate to offer means that while insurance providers administering plans in these states have to offer certain testing and treatment services, employers can decide which, if any, of those benefits to offer to people covered by their plan.
Group insurance plans
Most people are covered by group insurance policies. These are often plans offered by employers to their employees and some members of their family, and can be offered through a public or private provider (like Aetna and Cigna, among others). Unless you are a veteran or are current military personnel or their family, your plan is most likely provided by a private insurance company.
These are government insurance programs like Medicare, Medicaid, Veterans Administration (VA), and TRICARE.
VA health insurance coverage is available for those who served in the armed forces. It may cover certain conditions that result in infertility, and some patients may be eligible for coverage for IVF.
TRICARE is available for current military personnel and some members of their families. If you are covered by TRICARE, you may have coverage for certain reproductive services.
Affordable Care Act (ACA)
ACA covers individuals and small groups and requires minimum essential coverage for certain benefits. However, infertility is not considered an essential benefit by the ACA, so coverage is not mandated by the ACA or federal law. However, several state regulations mandate at least some coverage for fertility treatment.
If your appointment is through telehealth, check to see if it’s covered by your insurance policy before you schedule.
Still making sense of it all? We’ve got your back. See how it all breaks down and what it can mean for your fertility journey—visit the Know Your Coverage page.