Will Insurance Cover My Fertility Treatment? Questions to Ask Your Provider for 2023 Coverage
November 9th, 2022 | 7 min. read
The past few years have been full of ups and downs. Okay, a lot downs, for most of us. And finding out you are in need of fertility treatment in the midst of it all pretty much seems like a final blow.
People don’t plan on having trouble… in fact, we usually try our hardest to prevent "surprises," assuming everything is perfectly fine. So, finding out that you are going to need some assistance might be shocking, devastating, and heartbreaking.
Then your clinic shows you the price list of your different options.
Did you know that one cycle of IVF can cost somewhere between $12,850 and $24,250?
Surely your health insurance will cover your treatment needs, right? Eh…maybe - depending on your employer, insurance provider, and your specific plan. Unfortunately, very few health insurance plans cover fertility needs, which can result in you either paying out of pocket, seeking grants or loans, or halting your treatment altogether. We at Illume Fertility hate seeing patients stress over the financials of fertility when we wish they could focus all their energy into their end goal: having a baby.
But that’s why you’re here reading this blog. As we look ahead to 2023, you likely feel like you want to take control of your future. We 100% support that, and are going to help you figure all this out.
How Do I Pay for Fertility Treatment?
We’ve written a series of blogs lately that have covered everything you need to know about open enrollment and ways to pay for treatment outside of health insurance. Let’s review those options…
Have some money saved up for something unexpected? This might be the moment you use that surplus.
Paying out-of-pocket is not an option for many people. Grants are a great way to help supplement the costs of fertility treatments – you might even find some that pay for it all, top-to-bottom, medicine-to-procedure. Be mindful that grants typically have stipulations… you must use “this” fertility clinic, you must live in “that” state, etc.
Medical loans are another option – these are essentially out-of-pocket, as you’ll ultimately end up having to pay the loan back, plus interest. These might be a better option than just swiping your credit card for every bill, since you can negotiate a predetermined interest rate and payback period.
Often times, a fertility clinic will have financial options that either discount their services, or assist you in paying over a particular amount of time.
Get all the answers about financing your fertility journey:
And then there’s the option for which we all hope…
Health Insurance & Fertility Coverage
Wouldn’t this be dreamy?! Sometimes health insurance companies will cover partial or full fertility treatment. Some include a stipend for medication, some give you a lifetime monetary allotment - the coverage can vary. So that begs the question…
Will Insurance Cover My Fertility Treatment?
Will your health insurance cover your fertility costs? Below, we dive into how you can find out if your provider offers this benefit or not. The best way to get these questions answered? Call that handy number on the back of your insurance card.
First off, ask the obvious question:
Does my current plan cover infertility?
If your insurance policy DOES NOT cover infertility, head straight to your employer (the Human Resources representative) with these questions:
● Is there another plan I can switch to that does include infertility? Make sure to understand the grace period before using the fertility benefits! Some insurance companies require a certain amount of time to pass before dipping into benefits like infertility.
● Are there any company-based policies that would supplement my fertility journey? Some employers offer fertility supplementation or reimbursement separate from their health insurance. You may need to purchase a rider to your current plan, or a separate package through aEnother provider.
● Are there any other company policies I could take advantage of to assist my lifestyle as I seek fertility treatment? Maybe you have no opportunity for fertility treatment supplementation, but there’s a possibility they could help you in other ways! Think: a more flexible work schedule, more paid time off, etc.
If your insurance policy DOES cover infertility…
● Do I need to use a particular clinic? Some insurance companies will only cover your treatment if it's administered by certain clinics. Typically, the preferred clinics are ones that report to SART (Society for Reproductive Technologies), a third party information source with clinic statistics, and/or are Centers of Excellence.
● How do you define infertility in order to grant coverage? Some plans require a particular amount of time of trying-to-conceive or other health issues before allowing access to the extended coverage.
● Is all the fertility testing covered? Fertility testing must be done before any treatments are started. Is your HSG, saline sonogram, and genetic testing covered? You should ask about those specifically.
● What specific fertility treatments do you cover? Some insurances will not cover anything more than ovulation-inducing medication. Some will cover the entire gamut of procedures. Make sure to get a detailed list!
● Do you cover fertility medications? And a follow up: Will I need to use a specific pharmacy?
● Do I have any yearly or lifetime maximums on procedures or spend? Some plans place a cap on treatments in a given amount of time. For example, your lifetime allotment might be 3 IUIs and 1 IVF cycle, or 1 IVF cycle per year. Some plans will not put a cap on the type of procedures but will instead grant you a certain monetary stipend to be used on fertility needs in a given amount of time. For example, you could be given a $25,000 lifetime allotment.
Getting this answer will hopefully answer several of your other questions, like “how many rounds of IVF am I allowed?” or “what specific treatments do you cover?”
Other important questions to ask:
● Is there a particular order to the procedures that I’m required to follow? Meaning, will I need to do something less invasive like an IUI before IVF, or can I choose to do IVF first if my doctor recommends that treatment?
● Will I have a co-pay for office visits? And will all visits have the same co-pay, regardless of the purpose? You'll be in the office quite a bit between having bloodwork done, an ultrasound or diagnostic testing, or simply a chat with your doctor. Is it all the same co-pay?
● Do you cover pre-implantation genetic testing?
● Should I need ICSI in an IVF cycle, is that covered? ICSI is a more focused fertilization method (manually placing a single sperm inside one egg) that requires more intensive work by the embryologist.
● Do you cover cryopreservation? You might need to freeze your eggs or embryos, and you'll want to budget for those costs if they're not covered. A good follow-up question to ask: is there any coverage or reimbursement for the costs of keeping those specimens frozen year over year?
● How should we communicate from this point forward? Will your insurance company correspond directly with the clinic, or will they be contacting you with any results, approvals, or denials?
● What happens if I make it through my allotted coverage? Is there an additional package you could purchase?
● Do I have a deductible to work through before my fertility coverage is paid for? Ask about all the office visits you'll have, and if those payments can apply to your deductible, should you have one.
In addition to the questions above, here are a few insurance codes to ask about:
ILLUME FERTILITY's ID #: 873520733
IUI: 58322, 58323, 89260, 89261, S4042
IVF: 58970 58974
Make sure that by the time you get off the phone with your insurance representative that you are feeling comfortable, and understand everything they’ve said. You can also request to get the policy in writing.
It's Time to be Your Own Biggest Advocate
It’s incredibly important you do everything you can to understand your coverage and give your family building dreams a chance to come true. Now that we're in the midst of open enrollment, it's a great time to get on the phone and ask these necessary questions.
Be your best advocate, and let’s start the journey now. Cheers to your future!
Want to make the most of your coverage in 2023?
More Open Enrollment Resources
Sierra Dehmler is Illume Fertility’s Content Marketing Manager - and also a fertility patient herself. Combining empathy gained on her personal journey with her professional experience in marketing and content creation, she aims to empower and support other fertility patients by demystifying the fertility treatment process.