We know that understanding insurance benefits or obtaining the necessary referrals or authorizations to begin treatment can be very confusing. To minimize any financial anxiety, it is important to have a good handle on the pre-treatment processes that are required by your insurance plan. In order to assist you in this we have provided you with some tools for your insurance investigations.
Related Reading: Insurance Counseling for Infertility Patients
Understanding insurance coverage for infertility treatment
Here are some tools that may help to “demystify” your coverage for infertility treatment.
There are three major types of insurance policies: private indemnity, PPO and HMO.
- Medical services can typically be provided by any physician (choice of patient).
- May have a deductible and/or co-insurance.
- Insurance reimbursement is usually 50%-100%.
- Patient’s responsibility is up to 50% of the physician’s fee.
- May have an annual or lifetime maximum insurance payment for infertility benefits and medications.
Get the most out of your insurance
JoAnne Brian, director of practice development at Reproductive Science Center of the San Francisco Bay Area, shares how understanding the nuances of fertility medication and treatment insurance benefits can save patients thousands of dollars.
PPO (preferred provider organization)
- Medical services are rendered through a network of physicians that are contracted with the insurance company.
- Services may require preauthorization by the insurer.
- Deductible must be met before 50%-80% insurance reimbursement based on the usual and customary fees accepted by the physician.
- Patient’s responsibility is co-insurance and/or co-payments of the usual and customary, covered fees.
- Patients may have an annual or lifetime maximum insurance payment for infertility benefits and medications.
- Certain benefits may not cover all infertility treatment options.
HMO (health maintenance organization)
- Medical Services are provided through HMO contracted physicians.
- Services must be requested by the primary care physician or specialist and preauthorized by the HMO.
- Co-pays typically range from $5-20 per service.
- May not cover all infertility treatment options (IVF and other treatments may not be covered benefits).
HMO through IPA (independent practice association) or medical group
- Medical services are provided through direct contracts with independent physicians (like RSC). Services must be pre-authorized by the IPA.
- Co-pays typically range from $5-20 per service and 50% of contracted fees.
Tools for maximizing fertility insurance benefits
- Get to know your plan and your partner’s too.
- Call member services. The phone number is typically on the back of your insurance card.
- Get a copy of the contract and/or the summary plan description that includes a listing of included/excluded services, especially infertility services, treatments and medications.
- Determine the exclusions for coverage.
- Note that “infertility services excluded” means that neither diagnostic nor treatment are covered.
- Infertility covered, but no artificial insemination, nor assisted reproductive technology covered” usually means diagnostic procedures, surgery, or monitoring of drug therapy may be covered.
- Be your own insurance advocate.
- Insurance may not cover all infertility treatment options.
- Infertility may not be a covered benefit.
- IVF may not be a covered benefit.
Questions to ask your insurance company or employer
Fertility treatment can be a sensitive, time consuming, stressful and financially challenging journey. As part of your team, we would like to make it as easy for you as possible to achieve your dreams of having a family. Click the download button below to save a copy of our list of important questions to ask your insurance company or employer.