Infertility Insurance Coverage: Important Questions to Consider

Infertility Insurance Coverage: Important Questions to Consider Infertility Insurance Coverage: Important Questions to Consider

Dealing with upcoming infertility testing and infertility treatments and wondering if your health plan will pay? Figuring out insurance coverage is a daunting task. And with the high cost of infertility treatments such as IVF, having benefits is vital. Here are some questions and answers about infertility insurance that may help you on your path:

Q. What states cover infertility tests and infertility treatment?

A. At this time, insurance companies in some states (Arkansas, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, and West Virginia), are required by state law to cover infertility diagnosis and infertility treatment.

Insurers only have to “offer” infertility diagnosis and infertility treatment coverage in other states (California, Connecticut, and Texas). In these states, the employer may purchase a rider that provides coverage for infertility treatments and benefits.

The rest of the states have no regulations to cover infertility diagnosis and infertility treatments.

Q. What do insurance plans cover with infertility diagnosis and infertility treatments?

A. The benefits for infertility testing and infertility treatments vary from one plan to another. Also, if you work for an employer who is “self-insured,” then the state mandates may not apply. 

Q. What should I ask my insurance company about infertility treatments?

We have provided important questions below that you can ask your insurance company representative, Health Maintenance Organization (HMO), or employer (Human Resources or Benefits Department). Getting the right answers will help you assess your infertility benefits.  

Equally important, try to verify the responses you get.  You can do this by calling the insurance company 24-hours later. Now ask a different representative the same questions you asked the first one.

If you end up with different answers, then write a letter to your company.  State in the letter what you understand your infertility benefits to be. Then, ask the company to reply with a written confirmation of the information stated in your letter.

Q. What information do I need before contacting my insurance company or employer?

Before contacting a representative about coverage, have the following information available:

  • Your name (or name of the insured person)
  • The Employee/Patient ID Number or Social Security Number
  • The name of the employer
  • Name of the insurance plan
  • The group code or number
  • The patient’s name and date of birth

Also, ask for the name of the person with whom you are speaking and write down this name. Get the individual’s telephone and extension number; write down this information, too.

Getting answers to the following questions will help you figure out which infertility tests and infertility treatments will be covered:

Questions to ask your employer (human resources or benefits representative)

  • Does my current health plan cover infertility treatments?
  • Does another health plan provide benefits for infertility diagnosis and infertility treatments? What’s the difference in cost? How and when can I change plans?
  • Does my health plan have restrictions or limits to the benefits they pay for infertility diagnosis and infertility treatments?
  • What is the waiting period required before I can start infertility treatment for pre-existing conditions?

 Questions to ask your insurance company:

  • What are the infertility benefits in my plan? What is excluded?
  • Are there age limits for infertility treatment?
  • What do the benefits cover for infertility diagnosis and infertility treatment?
  • Does the plan cover infertility diagnosis procedures?
  • Does the plan cover infertility treatments?  
  • Does the plan cover fertility drugs?
  • Are any or all of the following covered in the health plan?
    • Lab and blood work
    • Progesterone and estrogen levels
    • FSH, LH, TSH, and prolactin levels
    • Semen analysis
    • Endometrial biopsy
    • Post-coital test
    • HSG (hysterosalpingogram)
    • Ultrasound
  • Are any or all of the following infertility drugs reimbursable?
    • Clomiphene citrate, eg, Clomid®† (clomiphene citrate tablets, USP)
    • Gonadotropin releasing hormone antagonists or agonists, eg, Antagon™ (ganirelix acetate) Injection
    • hMG (human menopausal gonadotropin)
    • hCG (human chorionic gonadotropin), eg, Pregnyl® (chorionic gonadotropin for injection, USP)
    • FSH, eg, Follistim® (follitropin beta for injection)
  • Must I use a certain pharmacy or can I use a mail order pharmacy to save money?
  • What types of infertility treatments are covered by the health plan?
  • Will I need to get a referral for any infertility diagnosis procedures?
  • Do I need a referral for infertility treatment?
  • Which clinics does the plan use for ART procedures? Am I restricted to using these clinics?
  • Which hospitals are affiliated with my plan?
  • Am I restricted to using certain specialists and assisted reproductive technology (ART) centers?
  • Do you have any physician profiles or comparative data to help choose a physician or ART center?

Inquire about insurance for fertility treatments

This content is Copyright The American Fertility Association (AFA) 2010. This content is intended for personal use and may not be distributed or reproduced without AFA consent. Please contact info@theafa.org or visit theafa.org for more information.

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