Insurance and Infertility - What you Need to Know
Your medical insurance is a big factor in out-of-pocket costs for infertility treatments. With the help of our dedicated Patient Financial Counselors (PFC), we have put together this document detailing some of the most important things you need to know when it comes to infertility treatment coverage and medical insurance.
Which is a better policy - per calendar year or dollar max?
The two most common types of policies that govern benefits for infertility coverage are: ones that cover a certain number of treatments per calendar year or lifetime, and ones that cover a maximum dollar amount per calendar year or lifetime.
Policies that offer treatments/year reset every calendar year. With a maximum dollar amount policy, you may max out your amount for that calendar year and have to wait until next year, or if you utilize your maximum dollar amount per lifetime, you may not be able to try again with the same policy.
Keep in mind that infertility medications can cost up to $5-7,000 for a single round, and can quickly eat up your maximum if it is included in your dollar maximum. Your Patient Financial Counselor (PFC) can help you optimize the different types of policies that are out there.
Is IVF covered by my Insurance?
In Illinois, infertility treatment is recognized as an essential health benefit (EHB), therefore, it is most often covered by insurances. However, in order to access this benefit, you must have a medical diagnosis of infertility. As a courtesy, your PFC can assist you with contacting your insurance company to provide an estimate of benefits. You can read the policies specific to Illinois here.
Is PGT covered by my insurance?
With exceptions, Preimplantation Genetic Testing (PGT), or genetic embryo testing, is seldom covered by insurances. Your PFC can help you understand your specific coverage and options.
Use an Insurance Broker
When switching or purchasing policies, you do not have to do it on your own. We suggest you explore and seek out an insurance broker online to help you select the policy that is best for you.
Questions to ask your insurance broker about a policy
- Is there a lifetime maximum on the number of ART cycles I can have?
- What is the maximum?
- Does it pertain to just the retrieval of the eggs and/or the frozen embryo transfer?
- Is there a dollar maximum for the ART benefit?
- What is the dollar maximum?
- Is the medication for infertility treatment (specialty pharmacy) benefit included in the dollar maximum? If so, what is that amount? If not, what is the separate amount?
- If the policy is not a lifetime maximum, is it a calendar year policy or a plan policy?
- Do I need to meet any special criteria to ‘access’ the infertility benefit?
- Do I need to obtain any type of authorization for ART and/or infertility services?
- Do I have to have my services performed at a ‘Center of Excellence’ to access my benefits?
- Does the policy cover Egg/Embryo/Sperm Cryopreservation?
- If medically necessary?
- Does the policy cover Pre-implantation Genetic Testing?
- If medically necessary?
- If so, what are the participation labs for this policy?
Think of the Big Picture
When considering switching to a new policy, make sure you look for a full policy that works for you overall, not just based on infertility treatment - think of the big picture.
Become your own best advocate
Lastly, we want patients to know that you hold a lot of power when it comes to your insurance. If you can, take the time to get involved and do your research. Patient and practice involvement carries weight. Our PFCs are here to help you, but we encourage you to become your own best advocate.