Understanding Your Fertility and IVF Insurance Benefits
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 Fertility Benefits
You should first try to find out how much fertility insurance 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 fertility benefits including IVF treatment; however, your employer has to purchase these features in order for you to be covered. Fertility insurance benefits exist 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 covers 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. Patients with IVF insurance from these plans do not have to pay out of network fees when undergoing IVF treatment at our facility.
2. Questions to Ask your Employer About Fertility Benefits
You can ask the Employee Benefit department at your company the following questions:
- Are there fertility insurance benefits in my health 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 plans?
- 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:
- Intrauterine insemination (IUI)?
- In vitro fertilization (IVF)- Number of cycles allowed?
- Embryo freezing?
- Frozen embryo transfer cycle?
- Are the fertility drugs covered (clomiphene, Gonal-f or Follistim)?
- 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?
4. Please Remember to Get Referrals and Authorizations
Please remember that it is your responsibility to obtain the required referral and authorization prior to your appointment if your plan requires you to do so. 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.