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Fertility Treatment - Insurance Check

Insurance Coverage & Benefits:

Insurance benefits vary widely, and it is impossible for us to cover every possible scenario of coverage factors with each plan. Because each plan is selected by you or your employer, it is important to call and get specific information about your insurance coverage before you begin treatment. This should be a coordinated effort and shared responsibility between you, your physician office and the insurance company to understand your specific coverage benefits. To assist in this process, we've provided standard questions which will help you when talking with your insurance company's member services representative. Your member service representative's number is listed on your insurance card.

Questions to Ask your Insurance Company

1. Does my insurance cover diagnostic evaluation for infertility (i.e. lab work, ultrasound, hysterosalpingogram, andrology services)? Does my insurance cover physician, hospital and lab charges?

2. Does my insurance cover treatment for Infertility such as artificial insemination or in-vitro fertilization?
Does my insurance cover physician, hospital and lab charges?

3. What is my copayment to an infertility specialist? (Remember, this is usually provided by a sub-specialist and can be different from your regular co-payment amounts.)

4. What is my copayment/deductible for infertility related hospital charges?

5. Does my insurance cover oral or injectable medications? (Clomid, Lupron)

6. Does my insurance require use of a specific contracted pharmacy?

7. Does my insurance require use of a specific contracted laboratory?

When working with your insurance company, make sure you have the appropriate authorizations before you begin any treatment plan. You are their customer and have more influence with your insurance provider than your physician or surgery center. Your involvement and assistance in coordination of authorizations, etc. is vital in the process to protect you from the surprise of becoming financially responsible if they do not pay. Remember, insurance authorizations can take up to 6 weeks, so be careful when rushing into a treatment or procedure without that authorization number!

California law requires insurers to offer infertility benefits to employers as an additional rider when they purchase their yearly insurance benefits. If your current employer does not offer infertility as part of your benefits package, this could be an area you could influence for future benefits decisions. Do not hesitate to make your voice heard in wanting and expecting infertility coverage be added to your benefits package through your personnel office.

If you Don't Have Fertility Insurance Coverage:

If you do not have insurance coverage for your fertility care, there are other options available for prompt payment for services. We have developed discounted global cash packages for different treatment options and we accept Visa, Mastercard, Discover and American Express.

Insurance FAQ's

1. Will my health insurance pay for any infertility treatment?

If your employer has purchased infertility as a benefit, it will be covered by insurance. Those benefits vary per employer. Our staff will do a complete benefit check and review your benefits at your financial consult.

2. If Insurance is involved, what is my financial responsibility?

Patient financial responsibility depends on what benefits your employer purchased in your insurance plan. Each employer is different in what they choose to provide as covered benefits. We will verify your insurance benefits before your appointment and we can help you understand your insurance coverage and your own financial responsibility during your financial consultation.

3. What insurance companies and medical groups to you belong to?

We are a contracted provider to all the major insurance companies and even some smaller insurance companies through a third party provider, with one exception which is Kaiser.

4. If I have no health insurance coverage, what is the cost of infertility treatment?

The costs can vary depending on what type of treatment is needed by the patient. SDFC offers patients numerous cash global discounted packages to choose from, as well as a success guarantee.

5. Do I have to get my insurance pre-authorization or do you do it?

If your insurance requires a pre-authorization to see a specialist, then you must get a referral from your PCP or OB/Gyn to see the fertility specialist for the initial appointment. After the initial consultation, our office will obtain any future pre-authorizations.

6. If my insurance plan requires a pre-authorization to see a specialist, can I be seen or start treatment without the authorization? Can I get a retroactive authorization?

Unfortunately, all plans that require an authorization will not issue retro authorizations. Retro authorizations usually only apply to emergency cases and infertility is not considered an emergency.

7. Do we know of any insurance company that a patient can purchase coverage for infertility treatment?

There are no individual plans that we know of that offers infertility benefits. The most common way a person gets insurance coverage is through their employer "group plan". A question to ask the employer is: "Can an employee pay a higher portion of the health premium to have an infertility rider as a benefit?

8. Why can my copay be 50% @ visit instead of my regular medical copay (i.e. $10.00)?

To most insurance companies, infertility is a "rider" to the basic medical plan. Some employers are able to offer infertility as a benefit by having the patient share in the cost by giving them a larger copay than the basic medical benefit. Therefore, there are different employers that may decide to purchase coverage that can be used for fertility treatments.

Who is to Blame for Missing Infertility Insurance Benefits? (published in our newsletter “Miracle News”, March 2005)

One of the first steps when starting fertility treatment is the insurance benefit check. Couples often find out that infertility diagnosis and treatment is covered by their
insurance, but IVF and other fertility treatments are excluded. The majority of SDFC patients reside in California, one state out of 13 with an infertility mandate in place. However, it is a “soft” mandate, which gives employers the option to offer infertility benefits. Since it is not required, not many employers actually purchase the coverage. Many patients are not aware of the fact that it is actually their employer who make the final decision about what is included in their company health insurance and what isn’t. So, instead of being upset with your insurance company, you might want to talk to your Human Resource Manager to find out what it would take to have them include advanced treatment like IVF in your insurance benefits. If you would like to make your voice heard on a higher level, send a letter to your U.S. Senator. The national self-support group RESOLVE encourages couples to call or write your U.S. Senator. For more information about your state’s mandate go to www.resolve.org and select “Advocacy”, where you can also find sample letters to Capitol Hill.

Last updated: November 27, 2007
Editors: Lisa Souza, Myna Helmi, and Kim Carnevale