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Understanding Your Insurance Benefits

First and foremost, understand your plan — what it covers and what it does not. We strongly encourage all new patients to call their insurance company to ask about the coverages that are and are not provided for infertility care. We have provided a list of suggested questions to ask your insurance company to assist you in determining your coverage.

Fertility Treatment Insurance Coverage

ACRM is contracted with various insurance networks. CCRM Atlanta is contracted with most, but not all of the same networks. Contact your insurance provider to confirm that both ACRM and CCRM Atlanta are considered in-network for your specific plan. If either is considered out of network, inquire if you have out-of-network benefits. Please note that we do not file claims for out-of-network benefits.

Insurance coverage and reimbursement issues for the treatment of infertility are complex. Many variables come into play in determining how much support these companies will provide, if any. The first question a prospective patient typically asks us is, "Are you in my network?" The truth is that this is not a simple "yes or no" question for a fertility clinic. In assisting our patients, we have seen that most insurance plans fall into one of three categories when it comes to infertility coverage.

  • The plan provides no coverage whatsoever for infertility services.
    • Thus, it really does not matter whether you see an infertility specialist in or out-of-network, because no infertility services are covered. This means that even if you go to an in-network physician who provides infertility services to you, you will still be self-pay because the service itself is not a "covered benefit." In this circumstance, even though a practice may be in-network to you, you will be responsible for payment in full since your insurance company will not reimburse for the services themselves.
  • The plan provides coverage only for the diagnostic phase of infertility services. In this scenario, the insurance plan will typically cover services rendered to determine:
    • That infertility does, in fact, exist, and if it does, what is the nature or cause of infertility.
  • The plan provides coverage for the diagnostic phase and some infertility treatment services, but not all treatment services.
    • In these circumstances, coverage is provided for some methods of infertility treatment but not others. For example, IUI may be a covered service, but not IVF.
    • For fertility services, you need to determine whether your plan covers diagnostic infertility services and infertility treatment services. If it covers infertility treatment services, it is important to know which services are specifically covered and which are excluded from being covered.

Other Infertility Insurance Scenarios

There are as many combinations of possibilities with these insurance scenarios as there are companies for whom the insurance plans are developed. Listed below are additional circumstances that we have seen with the various plans we have had contact with.

  • Although a plan may cover a particular treatment service, there is a limit to the number of services, e.g., not more than 3 IUI treatment attempts, not more than 2 lifetime IVF cycles, etc.
  • Oral medications may be covered, while injectable medications may not be covered.
  • There may be a maximum dollar amount stated in the policy that can be paid for infertility services, such as a $25,000 lifetime cap.

Keep in mind that there are no two insurance plans that are necessarily alike. The degree to which diagnostic services or treatment services are covered or not covered is strictly dependent on what your employer has purchased as coverage in the policy they obtained for your company. Even if you know someone in the same network or has the same insurance company, your two plans may be totally different.

What Does This Mean For You As An Infertility Patient?

  • Know your insurance plan. Know which infertility services (both in terms of diagnosis and in terms of procedures rendered) are covered and which are not. Understand whether these services are covered in-network only, or whether you have out-of-network benefits for these services. These are such complex issues that we feel it is important that patients take the step of finding out the extent of their coverage before treatment is even initiated.
  • Do not let the physician's status as being an "in-network" provider be the determining factor for selecting an infertility center. As you can see from above, there is no simple answer when it comes to insurance and infertility.