Understanding Insurance Benefits
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.
Fertility treatment can sometimes be a sensitive, time consuming, stressful and financially challenging journey. To make it as easy as possible, a series of frequently asked questions and answers have been compiled and made available for your convenience.
Understanding insurance coverage for infertility treatment:
Here are some tools that may help to “demystify” your coverage for infertility treatment.
There are three 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 80-100%
- Patient’s responsibility is 0-20% of the physician’s fee
- May have an annual or lifetime maximum insurance payment for infertility benefits
PPO – Preferred Provider Organization
- Medical services are rendered through a Network of Physicians that are contracted with the insurance company
- 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 fees
- Patients may have an annual or lifetime maximum insurance payment for infertility benefits
- 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 pre-authorized by the HMO
- Co-pay’s 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. Services must be pre-authorized by the IPA.
- Co-pays range from $5-20 per service and 50% of contracted fees.
Tools for Maximizing Insurance Benefits:
- Get to know your plan
- Get a copy of the contract and/or the summary plan description that includes a listing of included/excluded services.
- Determine the exclusions for coverage
- Note that “Infertility services excluded” means that neither diagnostic nor treatment is 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