Understanding Your Fertility Coverage and How to Use It
If you need to seek infertility treatment, your next likely question is “How in the world am I going to pay for this?” Hopefully, your answer is your insurance provider.
The first step is to figure out if your insurance policy includes fertility coverage and will help pay for the infertility treatments, tests, or other procedures your doctor may recommend. Maybe your insurance coverage includes a lifetime monetary stipend to use towards fertility treatment, or maybe it designates a set amount of IUI and IVF cycles. Maybe it includes only testing. Maybe your insurance plan doesn’t cover fertility at all. Just as every family is different, so is the insurance coverage for each of those families—or at least it seems that way. That’s why it’s so important to understand yours.
Your policy and the fertility coverage offered will vary by state, by employer, and by cost.
With this guide, you will learn the different insurance opportunities to look for, the places you can find answers about affordability, and other methods of paying for fertility treatment when insurance won’t cover everything you need.
Understand Your Insurance Coverage for Fertility Benefits
STEP ONE: Read your insurance policy.
This is admittedly time consuming and, well, not fun. But, much like other financial hurdles, it’s very important. Insurance policies are packed with information, medical and legal jargon, and fine print, but our biggest advice is to take your time.
- Look up terms as you read (Google will be your best friend)
- Review with your partner
- Write down the policy in a way you understand so you can refer back to your notes
- Write down all the questions that popped into your head that are still unanswered. If you have employer-based insurance, ask your human resources representative for help.
- 💡RMA of CT Tip: Before you even consider calling a provider or looking up your coverage, call the 800 number on the back of your insurance card and ask, "do I have fertility coverage? What does that entail?" Knowing that your initial consultation is covered can make calling a new practice a little less overwhelming.
What Does My Insurance Actually Cover?
As previously mentioned, there are many variations of fertility insurance coverage, and your personal coverage (if there is any) will be listed in your policy explanation. Unfortunately, there are still many policies out there that don’t cover fertility treatments, but hopefully, you have a plan that recognizes that infertility is a disease.
If you have a policy that covers fertility treatment, congratulations! There may still be limitations, so find out exactly what treatments and procedures your insurance will cover.
- Some policies cover procedures like in-vitro fertilization (IVF), but may not pay for medications, which are a critical, and often costly, component of treatment.
- Some policies cover a limited number of procedures - for example, 3 IUIs (intrauterine inseminations) and 1 round of IVF.
- Be aware of caps on coverage, whether they're annual or over a lifetime. For instance, a policy might say, “Here’s a $25,000 lifetime spending limit on fertility care.” ($25,000 sounds like a lot, but one IVF cycle can run you anywhere between $12,850 and $24,250.)
- And, while you may or may not need it, some policies cover the use of donor egg and/or sperm.
When you have less fertility insurance coverage
- Some policies may cover some, but not all, of your fertility treatment. For instance, a policy may only cover a consultation and tests like a hysterosalpinogram (HSG), vaginal ultrasound, saline sonogram, and hormone bloodwork. Additionally, those may cover a sperm analysis as well. (Wondering what to expect with a semen analysis? Check it out here.)
- You might be able to purchase “riders” to supplement your coverage. These are special insurance add-ons for, say, IVF treatment, that would pay for the treatment at a lower cost than an IVF cycle.
And then the bottom level of fertility coverage is no coverage at all. Unfortunately, many insurance plans fall under this category.
But wait – there is some good news! There is a wave of state mandates sweeping the country, making it mandatory for insurers in those states to cover parts of fertility care. Check to see if your state has any mandated coverage. See below for an overview of the NY, and CT Fertility mandate.
Connecticut law requires most insurance companies to cover infertility diagnosis and treatment, including up to four cycles of ovulation induction, a maximum of three intrauterine insemination (IUI) cycles, and up to two in-vitro fertilization (IVF) treatments. The Connecticut State Mandate requirements do not apply to employees in self-funded insured plans, or to employees who work for certain religious groups.
New York Residents
New York requires private group health insurance plans that are issued or delivered in the state, and that provide coverage for hospital care or surgical and medical care, to also cover the diagnosis and treatment of infertility for patients. They must be between the ages of 21 and 44, and have been covered under the policy for at least 12 months. The mandate provides up to 3 rounds of IVF, medically necessary fertility preservation, expanded drug coverage, and prohibits discrimination based on age, sex, sexual orientation, marital status, or gender identity.
Okay, so we get the state laws and the different levels of coverage, but, as you probably assumed, there are still more layers to your insurance coverage…
Not Every Fertility Clinic is Covered
This is another piece of the insurance puzzle – the Fertility Clinic. Some insurance carriers will work only with fertility clinics that meet certain criteria.
What accreditations and experience should you look for?
They may require the fertility program to be a center of excellence. A “center of excellence” is a fertility clinic that is recognized as a trusted, high-performing center that often gets preferential coverage by many insurers. Those centers are also more likely to report to the Society for Assisted Reproduction Technology. SART is an independent, unbiased organization that lists the annual pregnancy success rates of participating fertility clinics across the country.
Other accreditations and licenses may be required, such as the College of American Pathologists stamp of approval for laboratories.
It may be obvious, but it’s also really important that you like your doctor. And part of liking your doctor is the experience and training that they have gained during their years of practicing medicine. Don’t settle for less than a board-certified Reproductive Endocrinologist, the highest possible standard.
Need help choosing a fertility clinic?
What to Do When You Have Exhausted Your Insurance Options
No insurance coverage possibilities at all? You might feel like you’ve hit a dead end. But you haven’t, and rest assured that you are NOT alone! There are other ways to afford infertility treatment if insurance doesn’t cover all (or any) of your expenses.
Where can I look for financial help?
The first place you can look is your own income. Take advantage of your pre-tax savings options: Flexible Spending Accounts, Health Savings Accounts, and Health Reimbursement Accounts. These all allow you to put money away tax-free to pay for medical procedures.
The second option you should check out are nonprofit and government agencies offering grants that could cover some procedures.
In Connecticut, for example, the Nest Egg Foundation provides grants of up to $10,000 for patients undergoing IVF, if they can prove financial need and meet specific clinical criteria.
In New York, the state earmarks nearly $1 million annually for residents who earn less than $195,000 per year and who are good candidates for in-vitro fertilization. Eligible clinics all perform more than 100 IVF cycles annually and achieve at least a 30% success rate. The fertility clinics select the patients who will get the grants.
In addition, financing is available from several institutions, including many fertility clinics. When you visit a clinic, ask the staff how they might help you understand your insurance and find more money to pay for treatment.
What is Open Enrollment?
Open enrollment is the time you can change health insurance plans to make them more beneficial for you and your specific situation. If you find yourself dissatisfied with your insurance options, explore changes you might be able to put into place during this period, whether through your employer or the individual marketplace. The opportunity to make changes in the individual marketplace for 2021 began on Nov. 1 and ends Dec. 15, but you should also check with your employer, as their employer-based insurance open-enrollment dates may differ slightly. (We have an entire article devoted to helping you navigate the open-enrollment season!)
Paying for fertility treatment is one of the biggest stressors in the entire cycle. For many, it can be a huge weight on their shoulders, and we want you to know that we’re here to help. Now is great time to act if you’re interested in using your insurance for coverage or switching to a more all-inclusive plan, and more personally, we all know that we want to reach our goals as soon as possible. In addition to the many grants, loans, and payment plans that are available to you, we want to you offer you the best information possible so you can make these decisions for yourself.
We recognize that we covered a lot here, so we created a handy FREE downloadable guide to financial planning for fertility treatment. We hope you’ll take a look!
Ready to create a financial plan for fertility treatment?
About Virginia Hamilton Furnari
Virginia Hamilton Furnari is RMA of Connecticut’s Brand Specialist and has a background in writing, marketing, and content production. In addition to helping mold the RMA of CT brand through blogs, videos, and events, she is also a patient and has undergone many fertility treatments. Given her professional and personal involvement in the fertility community, she has immersed her mind, body, and soul in family-building education.