Insurance Coverage for Infertility

What Questions Do You Ask?

As you may already know, insurance coverage for infertility can vary greatly in scope, and coverage descriptions, either on a website or in your plan benefit summary, are sometimes vague. Unless your benefit reads either nothing or everything is covered, you should talk with someone at the insurance company. This should give you some idea of what your treatment cost will be.

We will also call your insurance company and verify your benefits. We will assume the information we're given is correct and file claims accordingly. Since your insurance policy is an agreement between your employer (on your behalf) and the insurance company (and you will be financially responsible in the end), we strongly suggest you also call.

What Is Your Name, and What Is the Call Reference Number?

When you call your insurance company, please be sure to get the representative's name on the other end and write it down. Ask if they provide call reference numbers; this will be very helpful if there are discrepancies in the future regarding how claims are being processed.

Is My Doctor In-Network With My Plan?

Even though it may seem basic, confirm that your doctor is considered in-network with your plan. Some plans may provide infertility coverage, but only with in-network physicians. Some insurance companies will designate physicians/practices as "preferred," affecting your benefit level. Your plan may pay at a higher benefit level if you're seen by one of them.

If you have out-of-network benefits, please be sure they exist in your home state. Even though it may say POS on your insurance card, the out-of-network benefits may only be there when you're away from home. Your insurance company expects you to stay within the network while at home. In other words, it acts as an HMO.

Do I Have an Annual or Lifetime Maximum Benefit for Infertility?

Ask about your plan's deductibles, maximums (annual or lifetime). Additional questions:

• Do I need to show a history of infertility before seeking treatment?
• Are specific treatment plans required before moving on to IVF?
• Will ultrasounds and blood tests performed in my doctor's office be covered?
• Are infertility medications covered?
• Must I use a specific pharmacy?
• Do services have to be authorized?
• If applicable, is infertility treatment covered after voluntary sterilization?

What Treatments or Procedures Are Covered?

When you start asking about coverage, be specific. Ask whether or not an infectious disease and genetic screenings (with no symptoms) are covered. Ask about testing to determine the cause of infertility and what happens once the cause has been determined (you have an infertility diagnosis). Do the benefits cover not only those services provided in an attempt to gain a pregnancy but also those services provided leading up to the attempt?

If at any time you feel like someone is reading off a screen and not answering your questions, hang up and try again. Feel free to ask for a supervisor. If the answers you are given don't agree with your understanding of your policy, call and ask again. If you feel comfortable going to your HR rep, let them know. After all, they negotiated the terms of your policy.

Even though you've completed your due diligence, your insurance company will still say, "a quotation of benefits is not a guarantee of payment ."However, you at least now have a reasonable expectation.

Related:

Insurance & Infertility, Questions To Ask