fertility news

Making the Most of your Insurance Coverage
2010

One of the most frustrating aspects of fertility treatment is having to open up intimate aspects of your personal life to medical professionals - and even insurance companies. But the reality is that insurance coverage can significantly impact your ability to afford treatment, and can even determine which diagnostic procedures you can have, or how many IVF attempts you can undergo.

What complicates the situation is that at present, infertility is not universally recognized as a legitimate medical condition to be covered by insurance, and coverage varies from state to state. For example, in some states only in vitro fertilization (IVF) or Ovulation Induction (OI) is covered while in others coverage for IVF or OI is specifically excluded from policies. (For a state-by-state list of coverage, see insurance coverage for fertility treatment.)

It is important to learn about your coverage before you even begin treatment. Allow yourself 6 to 8 weeks to accomplish these steps:

• Get a copy of your insurance plan's contract (not just the plan summary) and read the list of exclusions very carefully.
• Get the name of a specific person at the insurance company to contact about coverage.
• Ask your insurance company for a written predetermination of coverage, and then follow-up with your contact person to check on its status. (For more information on how to get a predetermination letter, see insurance coverage for fertility treatment.)
• Your fertility clinic will probably require a written statement of coverage from your insurance company in order to determine what fees must be paid up front.
• When you calculate how much your plan will pay, take into account the deductible, co-payments, maximum payment provisions or payment caps.
• Keep accurate records, retaining copies of all correspondence to and from the insurer. After all telephone conversations, write down the date, time, contact person, phone number and issues discussed.
• Don’t take "no" for an answer. If coverage is denied for a particular treatment, ask why. Find out whether various procedures used in the treatment can be covered independently.
• Ask a healthcare provider to submit the claims with the most specific billing and diagnostic codes possible. This increases the likelihood that at least part of a treatment will be covered. For example, while your plan may not cover infertility treatment, it might cover treatment for a hormonal imbalance that causes infertility.
• Ask someone with health insurance expertise at the treatment center to talk to the billing coordinator at the insurance company.
• Try not to be discouraged if you are initially denied coverage for treatment. Be persistent about resubmitting coverage requests and asking questions.

Other ways to defer costs

You will be held responsible for any costs not covered by insurance, so it's important to be prepared for those expenses. You may have access to a flexible spending account through your employer or a health savings account, which can help you set aside pre-tax dollars for fertility treatment. Ask your accountant whether you may be able to deduct some of your treatment expenses from your income taxes. Other options may include credit card offers, personal loans, or discounts on medications from various drug manufacturers. (For more information about these options, see insurance coverage for fertility treatment.)

Questions to ask your employer

If you are insured through your employer, here are some questions to ask your Human Resources or benefits representative:

• Are infertility treatments covered on the current health plan?
• Is there another plan that has infertility coverage? If so, what is the cost difference? Is it possible to change plans? If so, when?
• Are there restrictions to this plan’s infertility benefits?
• What is the waiting period before being able to start treatment for pre-existing infertility conditions?

If possible, speak to a different benefits manager the next day and ask the same questions, to make sure you receive the same answers. If the answers do not match, send a letter to the employer stating exactly what you understand your benefits to be and ask the company to reply with written confirmation.

Questions to ask your insurance company

Speak with a representative from your insurance company (or if necessary, a supervisor who better understands infertility benefits) to find out exactly which benefits are included and excluded under your policy. For example: Is there an age restriction for infertility treatment?

Am I covered for diagnostic procedures, drug therapy, and bloodwork? Do I need to use a specific lab or pharmacy? Do I need referrals for diagnostic procedures or treatment? Do I need to undergo specific tests before being referred to a specialist?

These are just a few of the important questions you need to ask your insurance company. For a more complete list of questions, see insurance coverage for fertility treatment.

Become your own advocate

As you can see, insurance coverage for fertility treatment is a complicated business. But by taking the time to understand your policy, you can make the most of your coverage and avoid costly mistakes. You don't have to be a financial wizard; you just have to ask the right questions and be persistent. This will help you make smart decisions as your pursue your goal of building a family.