Understanding Fertility Insurance Benefits

The most important thing to remember when you are talking about infertility with your insurance is you will most likely know more than the representative who is trying to help you. Unfortunately, misinformation can be a common occurrence when it comes to coverage for infertility services.

Researching your benefits through all available resources can help to affirm that you have received correct information or identify coverage your insurance company may have missed.

Possible available resources may include:

  • Telephone (contact numbers are usually listed on you insurance card)
  • Insurance Websites
  • Plan Booklet (Recommended)
  • Human Resources
  • Diagnosis

Most insurance plans provide coverage to diagnose infertility. It is important to determine whether or not you have coverage for diagnostic services or just coverage up to the diagnosis. Coverage for “diagnosing infertility” versus coverage “up to the diagnosis” can be a confusing subject. In some cases the term “up to the diagnosis” can describe coverage for one visit using an infertility diagnosis. The entire diagnostic process can take more than just one visit. You may receive an infertility diagnosis during your first visit to our office. If your insurance provides coverage “up to the diagnosis” you may want to take advantage of that one visit and request to have all testing possible at that initial visit. If your insurance provides coverage for “diagnostic services” this typically includes coverage for all services performed in the diagnostic process regardless when they are performed. If your insurance plan describes coverage to exclude infertility evaluations you do not have coverage for any of the diagnostic services.
Treatment

Although, coverage for infertility treatment is rare, for some it does exist. You have potential for having coverage for some services even when infertility treatment procedures are excluded from your insurance plan. Services or procedures performed to assist in an infertility treatment cycle such as Artificial Insemination and In Vitro Fertilization may be covered by your plan if they are not specifically excluded. The services performed to assist in these cycles are services that may have been covered by your plan for diagnostic purposes such as ultrasounds and blood hormone levels. If we are initiating a treatment cycle for you, the services provided during that cycle will no longer be performed as diagnostic they will be performed as part of the actual infertility treatment cycle therefore, determining coverage can be difficult.

We have discovered the easiest way to determine whether or not your insurance should cover services performed in the infertility treatment cycle by looking or listening for the verbiage in the benefit description to include or exclude “services performed in relation to” or “in conjunction with Artificial Insemination or In Vitro Fertilization.” If your insurance excludes infertility treatment and all services related, it is safe to assume any services performed within your cycle are not covered.

If your insurance plan describes coverage to include infertility treatment that can mean a variety of things. Infertility treatment can be defined as a surgical procedure performed to correct the cause of infertility such as surgery to remove tubal obstruction or re open a closed fallopian tube. Infertility treatment can also be defined as procedures such as Artificial Insemination or In Vitro Fertilization. Some plans describe treatment to include any service performed to help facilitate a pregnancy. You may be able to determine your coverage better by researching the actual procedures as opposed to researching coverage for infertility treatment. Our office will provide a checklist consisting of recommended questions to assist with this research.

Coverage for infertility treatments such as Artificial Insemination and In Vitro Fertilization is often accompanied by some sort of limitation or maximum specific to infertility services. It may include a limitation to your number of attempts using a specific procedure or a maximum amount of money your insurance will pay for infertility services. Certain plans will include qualifications you must meet prior to qualifying to use your infertility benefits or limitations that will exclude you from using your insurance benefits such as, a prior sterilization. These types of qualifications and limitations will vary from plan to plan, so be sure to research this thoroughly.

Medical and Maternity Coverage

Many times infertility may be caused from another underlining medical condition. In most cases your insurance will consider these medical conditions separate from your infertility benefit. If you are diagnosed with a medical condition such as endometriosis, a uterine septum or a fibroid your insurance will likely provide coverage for services provided to diagnose and treat these conditions as any other illness. In some circumstances your insurance may argue that you would not have been treated for these illnesses if you had not been attempting pregnancy. In these types of cases it is within your right to argue otherwise. This has proven to be a problem only in rare circumstances when your plan excludes all infertility services and your illness was discovered by chance with no symptoms present or if you have a specific exclusion on your insurance plan to exclude any surgeries performed on the reproductive system. Anytime you have a preexisting clause on your insurance policy be sure to research coverage carefully. A preexisting clause will cause exclusion for any service you were previously diagnosed with, within a certain time frame. Pregnancy cannot be considered a pre existing condition.
Once pregnancy is achieved your insurance will provide coverage for all of your services under your maternity benefit. If Maternity is excluded on your policy your services will not be covered with the exception of a complication of pregnancy. Most plans will cover any complication of pregnancy such as a miscarriage or tubal pregnancy. Maternity is excluded from most private insurance plans that you purchase on your own but is covered under most plans provided by organizations or employers. Be sure to research this benefit as well.
Please visit our site for a list of commonly used terms and definitions when working with your insurance.