Insurance Coverage for Infertility

Is infertility covered by your insurance policy?

This is a very good question that doesn’t have an easy answer. Nonetheless, if you are thinking about seeking medical advice/intervention to help you have a baby then you should know the answer to it. One reason this is so important to know is that coverage for fertility treatments varies widely from policy to policy, and if you aren’t careful you could end up being surprised by some large medical bills.

I want to touch on some basic concepts here for dealing with your insurance company in order to find out what type of coverage you have.

Ask Ask Ask!

This applies to many aspects of life, and is as simple (pretty much) as it sounds. If you don’t know the answers to something then just ask someone who does. Where this can get tricky is knowing who to ask. Our friend Google, or your search engine of choice, is great for finding quick answers to many of life’s little mysteries, but can be woefully inadequate in some queries.  For something as specialized as this you are much better off going to the source – your insurance company.

Talking to your insurance company

Now I know just the idea of talking to your insurance company can leave a bad taste in your mouth, but they are the ones who hold all the cards. They know what your benefit is, and more importantly make the final decisions around whether services will be covered under your specific benefit. The best way to get answers from an insurance company is to call the right person. Look for the customer service number on the front/back of your insurance card. If there is a separate # for members, great! Otherwise you may have to fight through some automated systems to get to a real life person.

Quick tip: you can sometimes skip to an operator by pressing “0” or saying ‘customer service’ or ‘operator’ even when those are not given options.

Once you get a real person on the other line there are a few tips to remember:

1. Don’t hang up until you get an answer you can understand. Lots of insurance companies outsource their call center labor overseas, and the person on the other line may just end up reading a benefit text verbatim back to you. Now if that answers your question, great! Otherwise, make sure you keep asking for clarification on anything you don’t understand until you get a straight answer!  This is especially important for infertility related questions, as it can be especially complex.
2. Don’t be afraid to ask for someone else if the first person you talk to cannot fully answer your question. Some insurance companies have separate divisions related just to infertility and they will be much better equipped to help you with any questions you might have.

Okay so you have someone competent on the line, what now? If you are looking into your broad infertility benefit than ask about that (This is where they will probably just read what is in your insurance benefit booklet back to you). A few things to listen for: The words ‘TOTAL EXCLUSION’ – this means you have no insurance coverage for infertility. If you go to a doctor for advice and or help to get pregnant you will be considered a CASH PAY patient and be responsible for the full amount yourself, often at the time of service. If you hear something along the lines of “..diagnosis of the underlying condition is covered, but any treatments are excluded,” then things are looking up! This means that likely have coverage for the workup (diagnostic phase where the doctors figure out what is really wrong with you so they can recommend the best ways to fix it/best treatments to work around your issue) which can save you lots of money. If you hear “diagnosis and treatment is covered” (lucky you!) keep listening as they will then list limitations to your benefit, often a # of attempts/cycles or a $$ limit.

Don’t forget about the fertility clinic

Another potential resource can be the fertility clinic you are going to be/are receiving services from.  They deal with this stuff day in and day out and can be invaluable in helping you with general questions and providing you with procedure and/or diagnosis codes (sometimes required to get more accurate information from your insurance). Remember that at the end of the day the fertility clinic is not making any decisions around what your insurance company does and doesn’t cover, so if you want a definite answer you will have to go to the insurance company yourself. Sadly, sometimes even then you will not be able to get a satisfactory answer.

Was this helpful? I plan on diving much deeper on many of the things I glossed over in this post so stay tuned ;) If you have any comments, alternate strategies that I didn’t mention, or just want to say hi, please do so in the comments below.

Cheers!