Understanding Your Insurance Benefits

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 coverage under the policy and how it is defined by the plan. It is also a good idea that you contact your employer to see if they offer fertility benefits in their benefits package as a “add on”, ie: Maven GOLD, Maven Access, Maven Green or Progyny.

Fertility Insurance Coverage

Insurance coverage for infertility can be very complex. Many variables come into play in determining how much support these companies will provide, if any. We have seen that most insurance plans fall into one of three categories when it comes to infertility coverage.

• The plan provides no coverage for infertility services.
  • You will be responsible for payment in full when services are rendered, since services are not reimbursable through your insurance company.
• 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 diagnosis.
  • This means that your initial consult, sonogram and bloodwork should be covered. However, there are times when the first initial consult is denied by the insurance company after filing your claim, even though there is diagnostic coverage under the policy.
• The plan provides coverage for diagnostic services 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.
  • Monitoring may be covered but not the procedures themselves.
  • 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 Scenarios

• 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.
• You may have to complete so many IUI’s before moving forward with IVF.

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

What Does This Mean for You?

• 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.