INSURANCE INFORMATION

Every year employers will review the cost of health care coverage to decide how much benefits they can afford to buy for their employees. The more coverage a policy has, the higher the premium the employer and, to some extent, the employee will have to pay. The state of Texas does not require employers to provide infertility benefits for their employees. 

1. KNOW YOUR INFERTILITY BENEFITS

You should first try to find out how much infertility benefits you are entitled to before starting treatment. There are differences in coverage within the same insurance company, depending on the plan provided for you by your employer. All major carriers such as Aetna, Blue Cross Blue Shields, Cigna, PHCS, and United Healthcare offer a wide spectrum of benefits including IVF treatment; however, your employer has to purchase these features in order for you to be covered. Infertility benefit exists at different levels:

	No infertility benefit. This total lack of infertility coverage is uncommon.
	Diagnostic testing only- This more common type of benefit covers procedures necessary to diagnose the causes of infertility such as sonogram, HSG, hormones levels, and semen analysis. It also cover diagnostic surgeries such as hysteroscopy and laparoscopy.
	Diagnostic testing and limited treatment- Benefits include diagnostic testing and treatment limited to ovulation induction and/or artificial insemination. Drug benefits may include clomiphene and, less commonly, the injectable medications.
	All treatments are covered- This is the most generous policy but it can change year to year. Coverage includes IVF treatment and injectable medications. There is often a limit on the amount covered or the number of IVF attempts allowed. We have direct contracts with Aetna, Cigna, and United Healthcare to provide IVF services.

2. QUESTIONS TO ASK YOUR EMPLOYER

You can ask the Employee Benefit department at your company the following questions:

	Is there any infertility coverage in my benefit plan? Is there any treatment benefit?
	Is there any other plan that has infertility coverage? If so, what is the cost difference? When can I change plan?
	If pre-existing condition restriction applies, what is the waiting period before I can start treatment?

3. QUESTIONS TO ASK YOUR INSURANCE COMPANY

You can get more specific information on infertility coverage by calling Member Services at the insurance company or by visiting its website. To facilitate the inquiry process you should have the following information ready: name of the insured individual, patient/employee ID number or social security number, patient's name and date of birth, name of the employer, name of the plan, and group number. Remember to get the full name of the person providing the information and  the contact phone number (with extension). When possible you should get the information in print. Below are the questions to ask:

	Is there coverage for diagnostic testing?
	Is there coverage for treatment of infertility? If yes, which of the following is covered:      1. Intrauterine insemination (IUI), number of attempts allowed?      2. Semen preparation for insemination?      3. Ovulation induction with clomiphene?      4. Super ovulation with one of the injectable medications such as Repronex?      5. Are the fertility drugs covered (clomiphene,  Repronex)?      6. In vitro fertilization (IVF)- Number of cycles allowed?      7. Intracytoplasmic injection (ICSI)?      8. Assisted embryo hatching?      9. Embryo freezing?     10. Frozen embryo transfer?
	Is there a lifetime maximum benefit?
	Is there a maximum benefit per calendar year?
	Is the medication benefit included in the calculation of the lifetime maximum limit?

3. REMEMBER TO GET REFERRAL AND AUTHORIZATIONS

A referral from your primary physician or your OBGYN is necessary for your first visit if you do not have the PPO plan. For subsequent visits, unless you have the PPO plan, you will be required to obtain authorization either from the insurance plan or from your referring physician. Most major plans in the DFW area (Aetna, Cigna, United Healthcare, BCBS) have a phone number listed on the insurance card that you can call to get authorization for subsequent visits. After each visit please keep track of the number of referrals you have left in order to contact your plan when you need to update the authorization. Since it may take up to several weeks with some insurance companies to authorize your treatment plan, you should plan for this in advance of your treatment.

Please remember that it is your responsibility to obtain the required referral and authorization prior to your appointment. If you don’t have a referral or an authorization, your insurance will not reimburse your visit and you will be ultimately responsible for the cost.

We will certainly work in cooperation with your insurance carrier to ensure that you will receive the benefits included in your policy. We will also file claims and attempt to negotiate disputed claims with your insurance carrier. However, you are ultimately responsible for payment of charges that are not resolved. In addition, expenses not covered by your insurance policy will be your responsibility. Our experienced and knowledgeable staff stands ready to assist you with your questions and claims.