Diagnosis and Treatment of Infertility: Am I Covered?
Determining whether your medical insurance coverage includes benefits for infertility can be a confusing and frustrating task. In some states (Arkansas, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, and West Virginia), insurance companies are required by law to provide coverage for infertility diagnosis and treatment.* In other states (California, Connecticut, and Texas), insurers are only required to offer this type of coverage; it’s up to each employer to purchase a rider that covers these benefits.* The remaining states have no regulations concerning infertility coverage.*
Although your state may be on one of these lists, the extent of the benefits to which you are entitled may still vary from one insurance plan to the next. In addition, if your employer is self-insured, the state mandates do not apply.* (*Since laws change all the time, we recommend you check with your state concerning its current regulations on infertility coverage.)
We have listed questions to ask your health insurance company, HMO (Health Maintenance Organization), or employer (Human Resources or Benefits Department), to help you evaluate your benefits. We recommend that you verify the answers you receive. To do this, simply call the company 24 hours or so after the initial phone conversation, and ask another representative the same questions. If the answers do not agree, send a letter to the company stating exactly what you understand your benefits to be, and request that they reply with a written confirmation of this information.
Contacting Your Employer or Insurer
Before calling your insurance company, HMO, or employer, have this information at hand:
- Name of the insured individual
- Employee/Patient ID # or Social Security #
- Name of employer
- Name of plan
- Group code/number
- Patient’s name and date of birth Be sure to get the name of the person to whom you are speaking and his or her telephone and extension numbers.
Answers to the following questions will help you understand which procedures will be covered and reimbursed during the course of your therapy for infertility. The information you obtain will also be useful to the insurance counselor at your doctor’s office. Remember, if you are unsatisfied with the answers you receive, ask to speak to a supervisor or to another representative who is more familiar with the infertility benefits.
Questions for your Employer (Human Resources or Benefits Representative):
- Are infertility treatments covered on my current health plan?
- Is there another plan that has infertility coverage? If so, what is the cost difference, can I change plans, and when can I change plans?
- Are there restrictions to the infertility benefits?
- What is the waiting period before I can start treatment for pre-existing infertility conditions?
Questions for your insurance company:
- What are my infertility benefits?
- What is excluded?
- Is there an age restriction for infertility treatment? If so, what is it?
- What do the benefits cover?
- Do they cover diagnostic procedures?
- Do they cover treatment procedures?
- Do they cover drug therapy?
- Which of the following are covered?
- Blood work?
- Progesterone and estrogen levels?
- FSH, LH, TSH, and prolactin levels?
- Semen analysis?
- Endometrial biopsy?
- Post-coital test?
- HSG (hysterosalpingogram)?
Which drugs are reimbursable?
- clomiphene citrate, eg, Clomid®† (clomiphene citrate tablets, USP)?
- gonadotropin releasing hormone antagonists or agonists, eg, Antagon™ (ganirelix acetate) Injection?
- hMG (human menopausal gonadotropin)?
- hCG (human chorionic gonadotropin), eg, Pregnyl® (chorionic gonadotropin for injection, USP)?
- FSH, eg, Follistim® (follitropin beta for injection)?
- Do I need to use specific pharmacies or mail-order pharmacies?
What types of treatments are covered?
- IUI (intrauterine insemination—ie, artificial insemination)?
- IVF (in vitro fertilization)?
- GIFT (gamete intrafallopian transfer)?
- ZIFT (zygote intrafallopian transfer)?
- ICSI (intracytoplasmic sperm injection)?
- Do I need a referral for diagnostic procedures?
- Do I need a referral for treatment?
- Do I need to undergo specific tests before being referred to a specialist?
- How do I get a referral?9001380
- Do I need a precertification?
- What does the precertification cover?
- How do I get a precertification?
- For how long is the precertification valid?
- Do I have a lifetime maximum benefit? If so, what is the limit?
- Do I have a calendar year maximum benefit? If so, what is the limit?
- Is infertility therapy included in the lifetime maximum benefit?
- Is infertility therapy included in the calendar year maximum benefit?
- What are the maximum allowed attempts for non-IVF procedures, such as ovulation induction and IUI?
- What are the maximum allowed attempts for ART procedures (ie, IVF, GIFT, ZIFT, and ICSI)?
- Does this number include only stimulation cycles or does it also include thaw cycles for embryos?
- Are freezing and thawing charges for embryo cryopreservation covered?
- Does the plan have a discounted rate for additional ART cycles?
- Are donor sperm and/or egg options covered?
- Is the egg donor covered by my plan if she has complications?
- Am I restricted to using certain specialists and ART (assisted reproductive technology) centers?
- Do you have any physician profiles or comparative data to help choose a physician or ART center?
- Who can I contact at my plan’s affiliated reproductive medicine clinics/programs to get more information about the services offered?
- Which clinics does the plan use for ART procedures? Am I restricted to using these clinics?
- Does the plan contract with outside providers to do vaginal ultrasounds or lab work? If so, which ones?
- Which hospitals are affiliated with my plan?
- Will the plan pay for me to get another medical opinion from a physician outside the health plan?
You can find out more about fertility and infertility diagnosis and treatment from the American Fertility Association. Browse our Web site http://www.theafa.org, or visit http://www.focusonfertility.org.
†Clomid® is a registered trademark of Hoechst Marion Roussel.