Use this guide to help you learn more about your health insurance plan’s fertility coverage
Be prepared before your first visit with your fertility specialist with these tasks and fertility coverage questions to ask your insurance company and our financial counselors.
Fertility treatment is stressful enough, but add in the complexities of health insurance and trying to figure out what fertility coverage you have and your stress levels can go through the roof. Because insurance plans vary widely, most people only have a vague idea of what their plan covers. And because many plans don’t fully cover fertility treatment, trying to figure out what they do pay for can be daunting.
Our financial counselors are here to help you navigate your specific insurance plan before your treatment begins. They’ve put together this list of things you should do and understand before your visit and fertility coverage questions to ask us and your insurance company.
How do state laws affect your coverage?
It’s important to understand state laws as they pertain to fertility coverage. Louisiana, for example, prohibits the exclusion of coverage for the diagnosis and treatment of a correctable medical condition, solely because the condition results in infertility. However, and this is a big “however,” the law does not require insurers to cover fertility drugs, IVF or other assisted reproductive techniques (ART), or reversal of sterilization, all the things that cost a lot of money. It’s a nice little loophole that lets insurers say “hey, we recognize that you’re medically infertile, but that’s on you.”
That being said, there are many employers who offer fertility benefits to their plans as a perk of employment even though they are not legally required to provide them. Starbucks, for example, recently began offering its employees enhanced benefits that provide coverage for IVF, fertility medications, and even surrogacy and adoption. Even many local employers have realized that offering fertility benefits can attract employees. Woman’s Hospital, Ochsner Health, and even Louisiana State University now provide some degree of fertility coverage in their employee health insurance plans.
What fertility coverage questions should you ask your insurance provider before your first consultation?
Before you visit us for your new patient consultation, the first thing to know is whether you have any fertility coverage, and if so, what kind. If you have health insurance through your or your partner’s employer, talk to the benefits person speak to an insurance representative directly and find out exactly what is covered from your health insurance.
If you do have some type of fertility coverage, ask what specific exclusions apply by asking your insurance coordinator these questions:
- Are initial consultations covered — and if so, how many?
- Does insurance cover diagnostic testing? While IUI or IVF and other ART procedures might not be covered, your blood work and ultrasound monitoring may be.
- Are medications covered, and do they need to be from a special pharmacy?
- Which ART treatments are covered? Are both intrauterine insemination and IVF included in coverage?
- Is there a waiting period before qualifying for IVF? Do you first have to try certain treatments, such as IUI, for example? (Some insurance companies require a few months of trying to conceive or a number of IUIs before beginning IVF)
- Is there a cap on your coverage? Is there a dollar amount, a cycle amount or a lifetime limit?
It may be challenging to get all the answers you need from your insurance company, but it’s well worth the effort. Be sure to take down the names of everyone you speak with so you’ll have a paper trail. Once you’ve made your appointment with Fertility Answers, ask to speak with our billing coordinator who may be able to provide additional details.
Watch out for these fertility coverage surprises
Oftentimes, even after thinking you have learned your fertility coverage backwards and forwards, many of our patients are surprised when a consult or a procedure isn’t covered. For example, many patients are shocked to learn that once they receive a diagnosis of infertility, their plan stops paying for certain tests.
Additionally, patients are often told by their insurance companies that “specialists” visits are covered. But, this often doesn’t cover an infertility specialist. Be sure to specify when talking to your insurance coordinator that you are seeing a specialist for infertility.
Another surprise to be aware of concerns “lifetime maximums.” Many patients think that if they have a lifetime maximum for infertility their insurance pays this amount in full and they have no responsibility. What is often the case is that the patients pays first toward their deductible and coinsurance until the lifetime maximum is met in full, then fertility benefits have been exhausted. The patient is then considered self-pay.
Have more fertility coverage questions we haven’t helped you answer here? Contact us to speak with one of our billing coordinators.
