Understanding infertility benefits with your insurance plan can be a daunting and confusing process. Although Neway Fertility verifies infertility coverage for all patients, it’s best to call your insurance company to re-verify coverage details and ask any specific questions regarding your benefits.
Below are some of the most important things to ask when obtaining information about your coverage for infertility.
1. Are there any specific requirements you need to meet before undergoing certain treatment cycles?
With some insurance companies, coverage for certain treatment cycles may not be immediate, even if your insurance provider tells you they cover that specific treatment.
For instance, in 2013 Aetna requires the majority of patients to undergo at least three cycles of injectable, medicated IUI cycles before they will begin covering IVF. These three cycles of IUI can be bypassed if there is a compelling reason proving the medical necessity for IVF. (It can take a lot of appealing to get these cycles approved). We see similar limitations with insurance providers Oxford and GHI.
2. Is your plan covered under state mandate?
There are currently 15 states that are required to offer infertility coverage to varying degrees. If your plan follows a state mandate, it is easiest to figure out what services you are guaranteed coverage. For example, a New York mandated plan offers coverage for all diagnostic testing and unlimited IUI attempts. IVF is not covered under NY-mandated plans.
For a full list of states that have infertility mandates, as well as more detailed coverage information (including limitations and qualifications for coverage), please refer to the American Society for Reproductive Medicine (ASRM) website.
3. Is there a maximum financial spend or a cycle limit for your infertility treatment?
Regardless of whether your plan is state-mandated, you may have a lifetime financial spending cap or a cycle maximum for infertility services.
With regard to dollar max, it is important for you to know if this cap is only for infertility treatment cycles (IUI and IVF) or for any service (such as tests and procedures) related to infertility. This will provide a better idea of how long your infertility coverage might last.
For example, if you have a $15,000 lifetime maximum for infertility services that includes all diagnostic testing, surgeries, IUI, IVF and drugs, one cycle attempt could deplete this fund. If the $15,000 applies specifically to IUI and IVF procedures, you will most likely have coverage for more than one cycle. If you have a maximum spend, it is best to follow up with your provider occasionally to check on the dollar amount they have applied towards the max in their system.
Conversely, cycle limits are usually easier to interpret. Some plans will specifically define IUI and IVF attempts covered separately, while other plans will have a total cycle max for IUI and IVF combined. Insurance companies count only completed cycles towards these limits, so if your cycle is canceled before the actual procedure, it will not count towards an attempt.
For any plan with a cycle limit, it is always beneficial to contact your insurance company after each cycle to follow up on your remaining allotted treatments. We have had patients who were mid-treatment and had their infertility limits changed by their insurance company without sufficient notification from the insurance. Changing from a cycle amount limit to a dollar amount max can alter your course of fertility treatments greatly.
4. Does infertility coverage change if you’re a single woman or are in a same-sex relationship?
Some plans and/or specific insurances have limitations if a patient has not been trying to conceive naturally for a defined amount of time. These insurance companies will require a certain number of self-pay cycles of IUI before they will begin coverage for infertility.
For example, many plans under Aetna and Oxford currently require single women using donor sperm or women in same-sex relationships to attempt 6 self-paid cycles of IUI before they will consider the patient as meeting the criteria for infertility. Additionally, even if your plan has coverage for IVF, an egg-freezing cycle for single women wishing to cryopreserve for future treatment(s) may not be covered if the provider requires a medical review of a cycle. Some insurance companies will deny coverage citing that the freezing cycle is not a medical necessity.
5. Are there age limits on your plan?
This will be the case with many state-mandated plans, but it is always good practice to ask this question. Many state-mandated plans and some non-mandated plans will cut all infertility coverage off by the age of 45. This means anything that is submitted to insurance with an infertility diagnosis code once a certain age has been met will not be covered.
6. Does your insurance require registration with an infertility program and/or authorization for treatment cycles?
Some insurance providers require a holder to contact specific departments before you even begin infertility treatment. Failure to do so means benefits will either be cut in half or not afforded. Neway Fertility will notify you if your plan requires you do to so. Below are insurance providers that require registration from nearly all patients:
- Aetna with the Aetna Infertility Program – 800-575-5999
- Oxford with Optum Health Managed Infertility Program (MIP) – 877-512-9340
- Empire United Government Plan with the infertility program – 877-769-7447
Depending on your plan, you may also require prior authorization for certain treatment cycles that we obtain in our office. Based on insurance, your cycle may not be covered if authorization is denied.
Of the insurance carriers we currently work with, Aetna and Oxford require authorization for all IUI and IVF cycles. GHI requires authorization for all IVF cycles. The Empire United Government provides authorization to patients for IVF cycles when the patient calls and registers with the infertility program.
Being informed before you begin treatment, staying on top of your insurance company and keeping yourself updated of your coverage can reduce the risk of unpleasant surprises and additional costs during your treatment. While we follow up with insurance coverage information frequently, it’s always best to re-verify the information by calling your provider’s member services.
If you’re unsure about coverage or any additional information you’ve been provided, please feel free to contact our office and we’ll work to find an answer.
Posted on behalf of
