Knowing your benefits
Financial considerations are an important part of any medical care, especially in the decision to pursue advanced fertility treatment. Our financial counselors are at your service to explain the cost of treatment and the extent of your infertility insurance benefit prior to initiating therapy. Their expertise allows them to help maximize the insurance benefits that may be available to you through your insurance plan.
Approximately 70 percent of our patients have some coverage for infertility treatment and 90 percent have coverage for their initial consultation.
Understanding your coverage
We understand that dealing with the insurance companies regarding your infertility coverage might be a little intimidating initially. To help cover expenses, it may be beneficial to add a flexible spending account (FSA). FSAs can be used to pay for medical expenses not paid for by insurance, such as deductibles, co-pays, and treatment not covered.
To find out the benefits available to you, request a copy of your benefits summary from your employer. Even if you have the same plan, benefits and out-of-pocket expenses may change from year to year.
Contact your HR department or your employer’s benefits coordinator if infertility isn’t listed on the Benefits Summary. Calling the insurance company directly usually does not help because your employer is the one who chooses the details of the plans they will offer. The customer service team at the insurance company often doesn’t have access to those details until members subscribe to a particular plan.
To gain a better understanding of costs for fertility treatment, explore the following aspects of your insurance coverage.
Pre-existing exclusions
Individual and small group policies typically have pre-existing clauses. Typical pre-existing conditions may state no documented history of infertility or may have a pre-existing condition waiting period (typically 9 months to 1 year).
Benefit exclusions
Examples of benefit exclusions may be prior sterilization, donor services, intrauterine insemination (IUI), and/or in vitro fertilization (IVF).
Benefit maximum
How much does this plan cover for fertility services or the number of cycles covered? Do medications contribute to the benefit maximum?
Plan type
Understand the differences between HMO/POS/PPO plans. Most HMO plans require that you see your primary care physician (PCP) to obtain a referral and authorization to see a specialist. Check to see which healthcare providers or hospitals are in-network.
Pre-authorization
Decide if you want to go through your primary care physician (PCP) to see a specialist and obtain referrals or have the ability to go directly to the specialist. Some insurance plans require pre-authorization.
Medication benefits
A medication (pharmacy) benefit is typically separate from your medical benefit. Try to find out if the plan has a medication benefit for fertility drugs.
Out-of-pocket expenses
Compare different plans, including deductibles, co-insurance, and any co-pay amounts (some policies have up to a 50 percent co-pay for fertility services).
Medical criteria
Check your insurance coverage to determine if there are specific medical criteria you must meet to be eligible for benefits. For infertility, criteria may include:
Verifying your benefits
In order to protect yourself from incurring fees that may not be covered by your insurance plan, we strongly encourage you to obtain written verification of your benefits.
Your new or updated insurance plan will not allow SGF to verify your benefits until they are in place with your insurance company. This does not happen until the start of the new calendar year or later. You may have proof of eligibility given to you by your employer, but until your benefits are actually loaded in your insurance plan’s system, we cannot access or obtain fertility benefits or authorizations on your behalf. Timing of new treatment cycles for the early week(s) after the first of the New Year has proven from experience to be particularly problematic.
General rules and requirements
Waiting time for authorizations
Gaining insurance coverage
Insurance benefits are employer-driven, each purchasing specific benefits and services for their employees. To find out your specific benefits, request a benefits booklet from your employer or human resources (HR) department. Even if you have the same plan, benefits and out-of-pocket expenses may change from year to year.
Open Enrollment is the specific period of time each year when you can make changes to your insurance policy (add, drop or change coverage). The Open Enrollment time frame is based on your employer but will typically fall between the end of October and the beginning of December. Most plan changes will go into effect on January 1 of the new year.
It’s important to find out if the plans being offered by your employer are accepted by SGF. Even if none of the plans being offered by your employer are accepted by SGF, you can still use your benefits if you have an out-of-network option on the plan. Most plans will list benefits for in-network and out-of-network on the Benefits Summary. There may be different rules for using benefits out-of-network and there is usually a higher cost associated with treatment for the patient.
