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Thank you so much for everything, we are so happy and blessed.” — SDFC Patient
Insurance Coverage for Fertility
Common Questions about Fertility Insurance Coverage
Before your first visit, our new patient patient coordinator will collect your insurance information so that we can perform a benefit check and confirm your insurance benefits. At your first appointment, our insurance specialist will meet with you to review and help you navigate the complicated world of insurance benefits. We are committed to making sure you take full advantage of your health insurance benefits.
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 benefits with you at your financial consultation.
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 the financial consultation.
What insurance companies and medical groups do 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.
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 plan.
Do I have to get my insurance preauthorization or do you do it?
If your insurance requires a preauthorization 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.
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 retroactive authorizations. Retroactive authorizations usually only apply to emergency cases and infertility is not considered an emergency.
Do we know of any insurance company from which a patient can purchase coverage for infertility treatment?
There are no individual plans that we know of that offer infertility benefits. The most common way a person gets insurance coverage is through his or her 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?"
How can my co-pay be up to 50 percent of the cost of each visit instead of my regular medical co-pay (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 co-pay 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?
One of the first steps when starting fertility treatment is completing an insurance benefit check. Call your insurance carrier’s number on the back of your insurance card and ask them directly to explain what is included in your policy.
Couples often find out that infertility diagnosis and certain treatments are covered by their insurance, but IVF and other fertility treatments are excluded. The majority of SDFC patients reside in California, one of 13 states 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 makes the final decision about what is and what isn't included in their company's health insurance. It may be best to talk to your human resource manager in order 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 their U.S. senators. 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.
Questions to Ask Your Provider: Fertility & Insurance Coverage
- 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?
- Does my insurance cover treatment for infertility such as artificial insemination or In-Vitro Fertilization?
- What is my co-payment to an infertility specialist? (Remember, this is usually provided by a sub-specialist and can be different from your regular co-payment amounts.)
- What is my co-payment/deductible for infertility-related hospital charges?
- Does my insurance cover oral or injectable medications (Clomid, Lupron)?
- Does my insurance require use of a specific contracted pharmacy?
- Does my insurance require use of a specific contracted laboratory?
When working with your insurance company, you’ll need to 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 does. Your involvement and assistance in coordinating authorizations, etc., are vital in order to protect you from the surprise of becoming financially responsible if they do not pay. Please remember, insurance authorizations can take up to six 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 to be added to your benefits package through your personnel office.
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.