Health insurance is indispensable, but it can certainly add to the complexities of the choices you make when pursuing infertility treatment.
At Reproductive Medicine Associates of Connecticut, we try to lessen that stress by helping you work with your insurance company to determine your level of coverage and your out-of-pocket expenses (when applicable). We also review with you the specific details of your insurance plan for infertility treatment.
We encourage you to be your own best advocate by thoroughly understanding your benefits before you begin treatment. Start by reviewing your specific policy requirements for covered and non-covered infertility services and asking questions of your insurer for clarification.
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It’s also important that both you and your partner provide us with your insurance information. We’ve found that oftentimes partners carry their own insurance with different requirements.
HMO (Health Maintenance Organization) – These plans usually offer only in-network benefits that normally require referrals or authorizations for all covered services. If your partner is covered under the same HMO plan, he’ll need to have referrals and authorizations for infertility services rendered to him as well.
POS (Point of Service) – These plans typically offer both in- and out-of-network benefits. Most POS plans require referrals or authorizations for the maximum benefit and the lowest out-of-pocket payment. Without a referral, you’re likely to be subject to an out-of-network deductible and higher co-payment. Authorizations are usually required for all infertility treatments. If your partner us covered under the same POS plan, he’ll need to have referrals and authorizations for services rendered to him as well.
PPO (Preferred Provider Organization) – These plans usually do not require referrals or authorizations for infertility treatments, but you should check with your insurance company as some require notification of services/cycles. If your PPO plan covers IVF, you will need a pre-determination letter from your insurance company verifying benefits in order to avoid paying for your cycle upfront.
Infertility Insurance Tips
When obtaining information on insurance coverage, don’t rely on just a phone call to the insurer. If you simply call and ask about coverage for a certain procedure, you risk getting incorrect information.
Instead, we strongly suggest that you request a written pre-determination letter or document from your insurance company detailing your exact benefits and any requirements that must be met in order to ensure coverage. This written document is your most effective tool if you need to challenge a decision or file an appeal for payment with your insurance company at a later date.
Establishing a point of contact with a representative at the insurance company is a good idea and may make follow-up easier. Keep a log of all phone conversations with your insurance company, including the date and time of the conversation and the name of the person with whom you speak.
During that conversation, get answers to these important questions:
What specific procedures do I need to follow to ensure that my infertility treatment is covered? For example, do I need separate referrals or authorizations for each office visit, blood work, ultrasound or procedure?
What are the qualifying criteria for receiving my infertility benefit? (i.e. previous attempts, a certain number of IUIs before being able to move onto IVF)
Is there a maximum dollar amount associated with infertility treatment? If so, what is it and how much have I used to date?
Is there a limit to the number of attempts allowed for intrauterine inseminations (IUI)?
Is there a limit to the number of attempts allowed for in vitro fertilization (IVF)?
Do I have prescription coverage?
Do I have a separate prescription plan?
Must I get my prescriptions from a particular pharmacy?
Is there a separate phone number I need to call to find out about my drug benefits?
Does fertility medication require prior authorization?
Common Fertility Insurance Terms
Referral – an insurance authorization number initiated when a primary care physician or OB/GYN refers a patient to a specialist. Obtaining referrals is the patient’s responsibility. A specialist’s name written on a prescription pad does not constitute a referral. Check with your insurance carrier for the proper referral procedure.
Authorization – a number issued by an insurance company authorizing a specific service or medication. Some insurance companies require that patients obtain authorizations and some require that the specialist does.
Pre-certification – a number issued in advance by an insurance company for a surgery or in-office procedure.
Pre-determination letter – a written verification of benefits issued by your insurance company in advance of your consultation or treatment.