Navigating insurance coverage for fertility treatments is an intricate process. Before embarking on any treatments, it’s crucial that you understand how best to utilize your current plan in order to maximize its efficiency.
First step should be contacting member services (typically located on the back of your card).
Review Your Existing Health Insurance Policy
Prior to beginning any fertility-related procedures, it’s crucial that you fully understand how your health insurance covers diagnosis and treatment costs. You can do this by asking your physician for a copy of the policy or calling customer service for your care plan.
Consult a person familiar with your policy’s coverage and limitations in order to guide decision making and identify effective treatment options that fit within your budget. They can also advise on using flexible spending accounts (FSA) or health savings accounts for services not covered by medical insurance policies.
Fifteen states currently mandate private health plans to cover at least some infertility treatments (“mandate to cover”). Of those states, nine include infertility diagnosis and/or treatments as part of their benchmark plan–meaning all new individual and small group policies sold must include this coverage.
State laws vary between fully-insured employer groups opting-in and self-funded insurance plans adhering to different rules. If your fully-insured employer allows them, contact them and ask to speak to a person who can explain how your current coverage handles infertility; be sure to keep detailed notes of this conversation, including who represented them at every turn.
Medical Tourism
Fertility treatments are considered elective procedures, meaning they’re usually not covered adequately by standard health insurance plans. As a result, individuals and couples often incur substantial out-of-pocket expenses to cover fertility treatments; many opt to travel overseas in order to lower these costs; this phenomenon is known as medical tourism, or cross-border reproductive care (CBRC).
Though some may hesitate to travel for fertility treatments, others are finding it to be both cost-cutting and convenient. Thanks to the Affordable Care Act and other factors, medical tourism is predicted to become increasingly popular over time.
Push factors include limited availability of services (e.g., HIV-related fertility treatment), higher costs associated with treatments at home (such as IVF) or lengthy wait lists for sensitive services like gender reassignment or drug rehabilitation; pull factors include low waiting lists.
Pull factors of medical tourism for endometriosis treatment abroad include wanting more privacy and confidentiality, the opportunity for less invasive procedures than available locally (e.g., endometriosis treatment) as well as lower treatment costs abroad. Medical tourists also express concerns over quality care received abroad and inability to obtain reliable information regarding available options and costs of treatment options.
State Insurance Laws
Twenty-one states have passed laws holding private insurance companies responsible for covering fertility testing, diagnosis and treatment services. However, it is essential to remember that state mandates are mandates “to cover” rather than mandates “to offer”. The distinction is critical since many states also include exclusions in their coverage; New York for instance requires insurers to cover IVF but excludes Medicaid/SHOP recipients as well as employees of small employers, religious employers and self-insurers from IVF coverage requirements.
Similar to HIPAA requirements, other state insurance mandates require patients to prove infertility prior to receiving coverage. This usually involves providing proof from a doctor that you have attempted timed unprotected sex for at least twelve months under 35 or six months if over 35; some states impose further time restraints such as five-year limits for egg and sperm freezing.
Understanding your state’s laws can be the key to planning ahead and budgeting for fertility treatments in the future. Doing your research will enable you to complete one of the primary tasks on your to-do list this year – building your family. No matter if your insurance covers fertility treatment or not, having more knowledge will allow you to navigate it more smoothly while saving you money along the way.
Insurance Benefit Check
Insurance benefit checks may help guide the coverage process more easily. Reaching out to either your clinic’s financial counselor or directly contacting your insurer directly may prove useful; just make sure they are familiar with fertility treatment coverage issues!
Dependent upon your policy, specific criteria must be fulfilled to gain coverage. These could include age restrictions or prior fertility treatments being taken; medical conditions that might reduce chances of successful infertility treatment being present; as well as caps placed by insurance providers on infertility services and medications they cover.
Find out more about your policy by calling the member services department of the insurance company whose contact number should be listed on the back of your insurance card. Additionally, request a copy of your contract or summary plan description directly from them.
Consider also what deductible and co-payment amounts you are responsible for when receiving coverage through an insurer, and whether or not they have an established network of providers with whom they have negotiated rates; often in-network providers have lower prices than out-of-network ones.
