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Insurance Coverage for Fertility Treatment

 

Where to Start

Understanding Fertility Coverage

Basic Types of Infertility Insurance Coverage

How to Determine Fertility Insurance Coverage
Infertility Insurance Resources
Advocate for Insurance Coverage

Where to Start:

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Understanding Fertility Coverage in Your Insurance Policy:

affordinginfertilityYour policy will dictate what fertility treatment is covered, whether you have IVF insurance coverage, what health care provider can provide this treatment, what tests you can have, the sequence of these infertility tests, and what fertility medications you can use. In short, unless you are independently wealthy, it dictates everything. As was stated in the great book, Budgeting for Infertility, Infertility treatment is a gray area; it's potentially very expensive, and [the insurance companies] are going to try to avoid paying if they can, even if it's covered. You have to know your policy. Know it word for word. Really study it. Be your own best advocate.


Preferably before going to an infertility doctor, you need the following information in writing (in the form of a pre-certification or pre-authorization letter):

  • What diagnosis procedures your insurance covers?

  • What treatments are covered (how many IVF cycles are covered? Is there a lifetime monetary limit?

  • What procedures require preauthorization?

  • What drugs are covered?

  • Are there any restrictions on who can deliver treatment?

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Basic Types of Infertility Insurance Coverage:

Like it or not, there is no such thing as a standard insurance policy or standard way health insurance addresses infertility coverage. You need to know the specifics about your policy. Most health insurance policies cover infertility in one of the following ways:

  • No fertility insurance coverage: Although, not common, it is possible. Most health insurance policies usually cover at least some aspects of the infertility diagnosis, even if it does not cover treatments such as in vitro fertilization. Diagnosis and treatment of conditions such as Polycystic Ovarian Syndrome (PCOS) and endometriosis are usually covered.
  • Insurance Coverage for Infertility Diagnosis Only: Most common. Insurance policy covers diagnosing the cause of infertility. It may cover surgeries necessary to diagnosis the cause. May specify what type of health care provider can perform these tests and surgeries.
  • Insurance Coverage for Infertility Diagnosis and Limited Treatment: Insurance benefits cover diagnosing the cause of infertility and limited treatment options such as clomiphene citrate (brand name Clomid), artificial insemination/ intrauterine insemination (IUI) with or without injectable medications.
  • Full Infertility Insurance Coverage: Wonderful, but rare outside of states that require insurance companies to offer fertility insurance coverage. Usually there is either a limit on the number of IVF cycles that are covered or a lifetime dollar amount limit to be used for fertility treatment.

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How to Determine Fertility Insurance Coverage:

  • Get a copy of your health care plan's Evidence of Coverage or Certificate of Insurance from your employer's human resource department or by calling up your insurance company. Usually the Summary of Benefits is not sufficient for the information you will need. If you already have a copy of this document, make certain it is the latest version. They change frequently.

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Resources:

  • Understanding Health Insurance Coverage - Ferring Reproductive Health offers a great explanation of the differnt types of insurance coverage. Also includes suggested questions for your insurer, questions for your employer, and a predetermintaion leter
  • Health Insurance Coverage for Fertility Treatments- An overview of how to determine what type of coverage you currently have. In the comments section, there are tips from an infertility doctor about ways to inquire into coverage without alerting your insurance company to a possible pre-existing condition.
  • Fertility LifeLines" at 1-866-LETS-TRY (1-866-538-7879) can answer your insurance questions.

  • Budgeting for Infertility by Evelina Sterling and Angie Best-Boss . I can't recommend this book enough. It is simply hands down the best resource available for figuring out how to pay for fertility treatment. They have a chapter on Insurance Coverage and a chart in the appendix on Evaluating Your Insurance Coverage.

  • Insurance Coverage for Fertility

  • Health Insurance for Fertility

  • Infertility Insurance Coverage

  • Health Insurance 101 - To understand insurance coverage for infertility treatment, you first need to understand how health insurance works and how to read a policy. It's not fun, but it can and must be done. This is not something you can leave to someone else, including the insurance specialist at your infertility clinic. You can rely on them, but you must also be educated. This is a good place to start.

  • "Infertility Insurance Coverage Basics: Tips When You're Trying to Conceive" By Kim Seidel. Good essay that covers the basics.

  • Infertility Treatments and Insurance: 5 Steps to Determine Coverage - Another very basic primer to get you started and equip you with enough information to ask questions.

  • National Conference of State Legislatures provides a great up-to-date list of every state laws as they relate to insurance coverage for infertility treatment. This is a must read when you are trying to figure out where your state falls in this coverage mess. Another summary of just those states laws that offer insurance coverage for infertility can be found here.

  • Understanding Insurance Coverage walks you through the beginning steps to understanding your insurance policy. The best advice is to get all insurance coverage discussions in writing, and this sites provides sample letters for you to use.

  • 65% of employers that offer insurance coverage for infertility treatment do so because an employee asked. If you don't ask, the answer is definitely "no", so what do you have to lose? Here's a sample letter for you to use. Employers are often afraid that including coverage for infertility will drive up their health care costs. Did you know that 91% of respondents offering infertility treatment have not experienced an increase in their medical costs as a result of providing this coverage. Other facts that you might want to include in your letter can be found here.

  • Insurance Coverage for Infertility Treatment: Study your plan to reverse claim denials. This 2002 article is dated, but the basic advice on how to appeal a claim if your infertility treatment is denied by your insurance company remains relevant.

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Advocate for Insurance Coverage for Infertility Treatment:

  • Infertility is a disease and deserves to be covered by insurance. We must do all we can to help educate others. We need you as an advocate for fertility insurance coverage. The best place to keep informed about advances and threats to insurance coverage for infertility is the Center for Infertility Justice at the Resolve website.
  • Ask your employer to provide insurance that covers infertility. Most employers who offer this coverage, do so at the request of their employees. Ask!

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