Exploring Fertility Insurance Benefits

Does your plan cover fertility treatment?

Employer-based insurance coverage varies from none to extraordinary (if working with a fertility insurance company like Progyny). Some states require a minimum or set the standard of fertility coverage, while others have no requirements. Check out your state at: Resolve.org’s Infertility Coverage by State. There are many variables. You could be working in California with state fertility coverage laws, but if your employer’s policy is written in Wisconsin, then only Wisconsin laws apply.

Fertility Benefits are Specific to Your Company’s Plan

If you or your husband/wife/partner has employer-sponsored insurance that includes fertility coverage, we can help determine your benefits when you meet with us.

What You Need to Know about Your Fertility Insurance

Referrals, Pre-Certifications, Pre-Authorizations

The first thing to understand regarding your insurance coverage is if a primary care physician referral is required for different types of treatment and a pre-certified authorization. Does your plan require pre-authorization? If so, you’ll need to know before meeting with a fertility provider.

Exclusions

Check for exclusions for any of these diagnoses:

Fertility testing
Unexplained infertility
Encounter for artificial insemination
Encounter for in-vitro fertilization

Treatment Plan

Once your treatment plan is identified, there are several variables to consider. For example, you may be limited to the number of IUI or IVF cycles that your insurance will cover. There also may be a lifetime maximum.

Check for treatments and other costs that may or may not be covered. For example:

PGT – Preimplantation Genetic Testing
Cryopreservation
Donor services (donor sperm or donor egg)

As a patient, you can be your best advocate for maximum coverage by thoroughly understanding your benefits. You must review your specific benefits, your policy’s requirements, and covered and non-covered services with your insurance provider.

While all of this can be overwhelming, our team is here to ensure that you have a thorough and transparent understanding of your coverage and the treatment process.

Insurance Terms to Know

Qualifying Medical Service Providers

Does your insurance require that you see only certain providers – those within their network, for example? Do the providers have to meet specific requirements for you to be reimbursable? Does your fertility clinic have to meet certain standards? Have the certification of national organizations which evaluate clinics, labs, or individual doctors? Blue Cross Blue Shield has Blue Distinction Centers for Fertility Care programs. Cigna has Centers for Excellence. Is a certain certification required, like Board Certification from the American Board of Obstetrics and Gynecology? Any details about the qualifications or requirements for providing coverage need to be discovered and documented to greatly increase your success in receiving the insurance coverage you have come to you.

Coverage

Insurance companies are usually very specific about what they will and won’t cover. They get down to the procedure and diagnostic codes and set conditions on when they will cover, how much they’ll cover, and when that changes. Coverage is a general term that indicates the insurance company paying any portion of the service, though it could be 5%, 25%, 80%, or 100%. Any amount of participation in paying the expense is called coverage. Understanding what kind of coverage – what % coverage and for what period is essential.

Minimums

Often we see that a minimum amount of medical services must be purchased before any insurance coverage is activated. It might be $300 in a calendar year. If you only spend $250 in a year, none of it might be covered. Usually, reaching the minimum expenditure triggers a period of co-pays, or coinsurance, where you pay a certain amount or percent, and the insurance company pays the balance. Then, depending on how your expenses grow, you may reach your maximum out-of-pocket for the year. It might be $1,000 a year or $2,000 or higher.

Policy Exclusions

Exclusions refer to what is not included, what the insurance policy does not include for coverage. Insurance policies may cover one kind of procedure but “exclude” or refuse to cover a similar procedure. They can exclude coverage in many ways, by age, by a pre-existing condition, by the number of expenses, and by who provided the service.

Policy Limits

Policy limits can apply to any period the insurance company chooses and specifies. You could have a quarterly limit. Many policies have annual limits, and with fertility insurance, often there is a lifetime limit or maximum. This could be a coverage limit to a maximum amount of insurance dollars a year or a lifetime. This could be expressed as a percentage of insurance expenditures; for example, fertility coverage can be no more than 25% of annual insurance expenses.

Pre-certification

Pre-certification is a notice sent by your healthcare provider to request elective, non-urgent services to a health insurance company. As with pre-authorization, the insurance company determines the decision to cover the service.

Pre-authorization

You must get permission from your insurance administration to approve the medical services you’re asking for. Usually, it requires medical records and physician documentation to designate why the procedure is requested. It must be approved BEFORE you receive services. The requirement is usually that the service is “medically necessary,” and the decision is in the hands of the insurance company. You are also known as prior authorization, prior approval. Pre-certification, while similar, is usually used for elective, non-urgent services.

After Out-of-Pocket Maximum

When you reach your out-of-pocket maximum, your insurer starts paying 100% of your covered medical bills until the policy year ends, or you switch insurance plans, whichever is first.

Out of Pocket Maximum

This is the maximum amount you will be responsible for a given period, usually a year.

CoPay and Coinsurance

You will continue to pay copays and coinsurance until you’ve reached the out-of-pocket maximum for your policy. Copay and coinsurance can mean the same thing, both you and your insurance company will be paying part of what is owed.

After your Deductible is Met

Once the total amount you pay for covered services adds up to your deductible amount in a year, your insurer starts paying a more significant chunk of your medical bills, which is your coinsurance.

Coinsurance

The amount your insurance pays once you have met your deductible.

Copay

You make these payments each time you get a medical service after reaching your deductible. Your copayment, or copay, is a fixed amount you pay each time you receive a covered health care service.

Deductible

Your plan’s deductible is the specified amount of money you must pay for covered health services before an insurance company will start to pay anything.

The Clinic, Lab, and Doctor Certifications

You may have to work with clinics with certain certifications to be approved by your insurance. Atlantic Reproductive Medicine has the following certifications and accreditations:

SART

College of American Pathologists for Laboratories

Laboratory Accreditation Program

CAP Accredited Reproductive Laboratories

Board Certified Reproductive Endocrinologist (the highest standard)

RMA

In-Network Insurance Companies

AETNA

Blue Cross / Blue Shield

Cigna (We are a Center of Excellence with Cigna)

Progyny

Progyny’s innovative, all-inclusive benefit design allows patients and their doctors to pursue the most effective treatment, the first time, without worry that coverage will be exhausted in the middle of treatment. They partner with the nation’s leading employers to bring fertility coverage to over 2.2 million people. Progyny offers its fertility insurance plan “Smart Cycle” through participating large employers. It includes all your office visits, tests and treatments.

On the Progyny website you will find Atlantic Reproductive Medicine listed as a clinic near Raleigh, NC.

Out of Network Insurance Companies

Tricare Prime and Tricare Members

Tricare Prime members are out-of-network and therefore, patients must have a referral from their PCM to schedule an appointment. It is the patient’s responsibility to obtain the referral. Atlantic Reproductive Medicine is able to file for all diagnostic testing with limited coverage expected. Patients should contact Tricare for coverage details.

Tricare members are out-of-network for treatment services. However, Atlantic Reproductive Medicine is able to file for all diagnostic testing with limited coverage expected. Patients should contact Tricare for coverage details. Tricare members do not a referral from a PCM to schedule an appointment at Atlantic Reproductive.

United Healthcare

For information on submitting your own claims, click here: https://www.uhc.com/member-resources/how-to-submit-a-claim
To learn which codes you will need for your submission, click here
To submit your United Healthcare claim, click here: Direct Medical Reimbursement (uhc.com)

Optum Care Management

Some Insurance carriers use Optum to manage their fertility coverage. You may have an insurance carrier that falls into this category. We suggest you speak with your insurance company to see if they use Optum Care Management for fertility coverage. We may be in network with your insurance company but not with Optum which manages the fertility benefit.

Learn More at the National Infertility Association

The National Infertility Association at Resolve.org is a helpful resource regarding insurance coverage, as well as other fertility-related topics. Here are some helpful links:

Infertility Coverage by State

Fertility Health Insurance 101

LGBTQ+ Family Building Options

Treatment Options