November 4th, 2024 | 11 min. read
Understanding which fertility benefits your insurance provider offers (if any) can be a daunting process. Even when your fertility clinic verifies coverage, it's important to call your insurance company to confirm all the details and ask any additional questions you may have.
In this article:
Do I even have infertility coverage?
No one plans on having trouble conceiving. In fact, many of us spend years actively trying to prevent surprise pregnancies, only to discover that the path to parenthood isn't going to be as straightforward as we expected.
As you begin exploring your options, it's easy to get overwhelmed by the cost of fertility treatment and question whether you will even be able to afford the care you need to make your dreams come true.
It's no secret - insurance policies are notoriously difficult to interpret. There are several places to turn for help understanding your coverage:
- Your employer’s human resources (HR) department
- Your fertility clinic’s finance or billing department
- Your health insurance provider's customer service department
In this guide, we will walk you through the most important questions to ask in order to determine your level of coverage for fertility-related testing and treatment. By the end, you'll feel more informed and empowered as you take the next steps towards achieving your goals.
Will insurance pay for my fertility treatment?
While an ever-increasing number of employers and health insurance companies are now recognizing the importance of covering infertility-related costs, not all do - and many policies still involve frustrating restrictions.
After you've reviewed the questions below (adding any of your own), the next step is to call the number on the back of your insurance card and start the conversation. Remember: Customer service representatives are there to help you. Don't feel rushed or like your questions aren't important.
You deserve their time - and accurate, clear answers!
Note: Some states (including Connecticut and New York) now mandate fertility coverage from employers. To see whether your state has a state mandate in effect, and learn how to interpret the language involved, visit RESOLVE's Insurance Coverage Map.
What to Ask About Fertility Coverage
Now that you know where to find support understanding your policy, the next step is knowing what to ask. That's why we've compiled a comprehensive list of questions to ask your HR department and insurance provider before beginning fertility treatment.
Questions to Ask Your HR Department
Start with the obvious: Does my current plan cover infertility?
If your insurance policy does not cover infertility, head straight to your employer's human resources representative with the following questions:
Is there another plan I can switch to that does include infertility?
If switching plans is an option, make sure to clarify if there are any restrictions on using your new fertility benefits. Some insurance companies require a certain amount of time to pass before dipping into benefits like infertility coverage.
Are there any ways to supplement coverage for my fertility journey?
Some employers offer fertility supplementation or reimbursement separate from their health insurance. You may need to purchase an insurance rider on top of your current plan, or a separate package through another provider.
Are there any company policies that can support me as I seek fertility treatment?
If you discover you have no opportunity for fertility coverage supplementation, there’s still a possibility that your employer could help support your journey in other ways. For example, offering a more flexible work schedule, more paid time off or sick days, etc.
Pro tip: Download RESOLVE's Coverage at Work Employee Toolkit to learn how to approach your employer and push for expanded fertility benefits at your company.
Infertility, redefined.
Learn how the American Society for Reproductive Medicine's updated definition of infertility will increase fertility coverage for more hopeful parents.
Questions to Ask Your Insurance Provider
The following list of questions will help you keep track of all of the most important things to discuss with your insurance provider's customer service representative:
Will I have to use a particular fertility clinic?
Some insurance companies will only cover your treatment if it's administered by certain clinics. Typically, the preferred fertility clinics are ones that report to the Society for Reproductive Technology (SART), a third-party information source that publishes yearly clinic statistics, though your insurer may have other requirements.
How do you define infertility in order to grant coverage?
Some insurance plans require a specific amount of period with "exposure to sperm" (i.e. trying to conceive without assistance, for opposite-sex couples) or other specific diagnoses before allowing access to extended fertility coverage.
Other questions to ask:
- Is there an age limit for fertility coverage?
- Is pre-authorization required before beginning treatment?
Do I have to meet a deductible before fertility coverage kicks in?
Ask about all the office visits you'll have throughout your fertility journey, and if those copays will be applied to your deductible, should you have one.
Is all fertility testing covered?
Fertility testing is an essential part of the process and must be performed before any treatments are started. To avoid potentially costly surprise bills, you'll want to check if diagnostics like hysterosalpingography (HSG), saline sonogram (SHG), and genetic carrier screening are covered.
Other questions to ask:
- Does my policy require the use of a specific, contracted laboratory?
- Will any lab charges at my fertility clinic be covered?
What specific fertility treatments do you cover?
Some insurance policies won't cover anything more than ovulation induction medication. Others will cover a wide range of fertility treatment pathways. Make sure to get a detailed list!
Is there a particular order for procedures I'll need to follow?
Many insurance policies require you to start your journey with a less invasive treatment option (such as ovulation induction or IUI) before they will cover IVF treatment. Also ask: Can I skip ahead to IVF first if my doctor recommends it?
Do you cover fertility medications?
Medication is a big part of most fertility journeys, and can cost thousands of dollars - so you'll want to be sure they are covered. Also ask: Will I need to use a specific pharmacy?
Do I have yearly or lifetime maximums on procedures or spend?
Some plans place a cap on how much fertility treatment will be covered in a given period of time. For example, your lifetime allotment might be three IUI cycles and one IVF cycle, or perhaps one IVF cycle per year.
Some plans don't put a cap on the type of procedures, but will instead grant you a certain monetary stipend to be used on fertility care. For example, you might be given a $25,000 lifetime allotment. Always ask your insurer to clarify what this means for you.
Other questions to ask:
- How many rounds of IVF am I allowed?
- What specific treatments do you cover?
- What if I make it through all of my allotted coverage?
- Is there an add-on package I can purchase?
Will I have a copay for office visits?
And will all of my visits have the same copay, regardless of the purpose?
You'll be at your fertility clinic quite a bit between getting blood work, ultrasounds, or diagnostic testing - or simply a consultation with your doctor. Be sure to ask this question so you don't rack up unexpected charges at every single visit.
Reminder: A copayment (copay) is a set fee you pay at a doctor's appointment or when you pick up a prescription. Some plans have $5 copays, others are $25 or higher.
Do you cover preimplantation genetic testing (PGT)?
PGT refers to a series of screening tests that can identify genetic abnormalities in embryos created through in vitro fertilization (IVF). This is especially important for those who are carriers for genetic disorders, such as cystic fibrosis.
If I need ICSI in an IVF cycle, will it be covered?
Intracytoplasmic sperm injection (ICSI) is a hyper-focused fertilization method where an embryologist manually injects a single sperm inside an egg. ICSI can be essential to IVF success in cases of male factor infertility, for example.
Do you cover cryopreservation?
Most fertility patients end up needing to freeze some eggs and/or embryos, so 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 specimens frozen year over year?
How will we communicate from this point forward?
It's important to know whether your insurance company will correspond directly with your fertility clinic or if they will be contacting you directly with results, approvals, or denials.
Make your dream a reality.
Don't let finances stand in the way of building your family. Explore more ways to pay for treatment without insurance coverage now!
Insurance Codes for Infertility
Another helpful thing to discuss with your insurance provider is specific procedure codes. Here are the most commonly utilized insurance codes for infertility treatment at Illume:
- Illume Fertility ID#: 873520733
- IUI: 58322, 58323, 89260, 89261, S4042
- IVF: 58970, 58974
Remember: By the time you get off the phone, you should feel confident that you understand everything they’ve said. If you don't, you can always call back! You can also request to get your policy in writing so it's easier to reference.
5 Ways to Pay for Fertility Treatment
Here's a quick summary of the five most common ways to finance a fertility journey:
1. Out-of-Pocket
Have some money saved up that you can put towards treatment? This might be the moment you dip into that surplus. However, for many people, paying out-of-pocket is simply not an option, with fertility treatment costs ranging from a few thousand dollars to $180,000+ (for pathways such as gestational surrogacy).
2. Financial Grants
Financial grants are a great way to help supplement the cost of fertility treatment – you might even find some that cover the entire process (testing, medication, and procedures). Grants typically have stipulations (i.e. must use a specific clinic or live in a particular state in order to qualify for application).
Always read the fine print!
3. Medical Loans
Medical loans are another option for some people. However, it's critical to note that these are essentially out-of-pocket, as you’ll ultimately end up having to pay the loan back (plus interest).
Still, loans might be a better option than just swiping a credit card for every bill, since you can negotiate a predetermined interest rate and payback period for the loan.
4. Fertility Clinic Plans
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. At Illume Fertility, we offer a variety of plans that can help make the journey more accessible.
After you schedule your first consultation, you will receive more information and be assigned a personal Financial Counselor who will help you understand what Illume's plans entail.
And then there’s the option we all hope for...
5. Health Insurance
As you now know, some health insurance plans will either partially or fully cover the costs associated with fertility treatment.
However, one insurer may include a stipend for fertility medication, while another insurer may give you a lifetime monetary allotment - the options vary widely. That's why understanding (upfront) what your policy offers is so critical.
Knowledge is Power
It’s important to do everything you can to understand your insurance coverage and give your family-building dreams a chance to come true. While spending time on the phone with insurance and HR representatives may take some effort now, asking these necessary questions will pay off in the long run - and may even save you thousands of dollars!
Have more questions about affording fertility treatment? Reach out to our team!
No insurance? We can help!
Explore other options for affording fertility treatment with our helpful guide.