Insurance & Mandates

Learn which insurance providers Illume Fertility accepts and get more information about Connecticut and New York state mandates for fertility coverage.

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Insurance Accepted by Illume Fertility

Note: We are not in-network with Medicare, Medicaid, Fidelis or any other government funded plans. If you have an HMO plan, you may require a referral to Illume Fertility.

How can a state infertility mandate help me afford treatment?

Only 19 states in the United States have infertility mandates for insurance coverage - and we are lucky to have mandated coverage in Connecticut and New York!

While these state mandates do have limitations and exclusions, they can help residents of both Connecticut and New York afford fertility treatment by requiring large group insurance providers to cover certain fertility tests, treatment and other procedures related to infertility.

Learn more about the CT and NY mandates:

CT Mandate NY Mandate

Fertility Insurance Coverage

Health insurance is indispensable, but it can certainly add to the complexities of the choices you make when pursuing fertility treatment.

At Illume Fertility, 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 the specific details of your insurance plan for infertility treatment with you.

To help you get started, we explain the different types of insurance plans and offer infertility insurance tips below.

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Types of Insurance Plans

Learn more about the three main types of insurance plans and how they typically work.

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, they will need to have referrals and authorizations for infertility services rendered to them 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 is covered under the same POS plan, they will need to have referrals and authorizations for services rendered to them 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 just rely on a phone call to your 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.

What else should I do?

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.

Insurance Mandate

Some states mandate coverage of some kind of infertility treatment. State mandates vary widely. Some mandates apply only to certain types of health insurance policies like HMOs. Others specify coverage for only certain types of infertility treatment, such as IVF.

Premium

The baseline amount you pay monthly for health insurance. This can be paid directly to a health insurance company or via a paycheck deduction through your employer. Your premium does not include deductibles, copays, or co-insurance.

a comprehensive guide to

Financial Planning for Fertility Treatment

Understanding fertility treatment financing is no simple task. We're here to help break it all down for you and make it just a little bit easier. Explore budgeting, how to maximize your insurance coverage, take advantage of open enrollment, learn about Illume Fertility's Opportunity Plans and much more.

Fill out the form to download your comprehensive guide to financial planning for fertility treatment today.

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Have more questions?

Illume Fertility can help.

Our team of eight board-certified reproductive endocrinologists and comprehensive support staff are ready to help you create the family of your dreams.

Take the first step by scheduling your consult today to learn how Illume Fertility can help you achieve your goals, or download our free Financial Planning for Fertility Treatment eBook.

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