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Question 21. Will my insurance pay for my fertility treatments?

Posted Apr 21 2010 1:37pm
Obviously healthcare reform has been a hot topic here inside the beltway this past year. No doubt that trying to navigate the insurance coverage jungle is confusing to say the least. Most plans cover diagnostic testing for infertility. Some plans cover treatment for infertility. Some plans only cover certain treatments and dictate a specific order to those treatments. Some plans cover a certain dollar amount and couldn't care less what treatments you do....and on and on and on.

Sometimes patients ask us to code visits using non-infertility codes. In other words, a patient is sent to me by her Ob Gyn for infertility and we spend 35 minutes discussing only infertility. Then she asks me to code the visit as endometriosis because her sister has endometriosis and so perhaps maybe she also has endometriosis and that is what is causing her infertility. There is a term for this request....insurance fraud. As much as I love my patients (especially those that read this blog....both of them), I am not prepared to go to the "big house" on their behalf. Sorry but no. I am not prepared to spend a few years behind bars. It may have done wonders for Martha Stewart's career but I have no interest in that type of life experience.

So here is today's Question of the Day21. Will my insurance pay for my fertility treatments?

Insurance coverage for infertility varies widely across the United States. Several states, including Massachusetts, Illinois, and Maryland, have passed legislative mandates for infertility coverage. In these states, access to fertility treatment is guaranteed through the patient’s employer. In the vast majority of states, however, fertility coverage is inconsistent. Some companies may offer extensive fertility benefits, while others offer no coverage at all to their employees.

It is important that you understand your specific benefits before you seek out any kind of fertility treatment. Insurance plans may provide a specific dollar amount to spend on fertility treatments or cover a certain number of cycles of either IUI or IVF. You should work with your fertility provider’s billing staff to determine which benefits are available to you before launching into a treatment plan. Given that some insurance plans may cover infertility more extensively than others, it is always appropriate to examine your insurance options during periods of open enrollment for health benefits. Many insurance companies will not cover fertility treatments in patients who have been voluntarily sterilized (e.g., vasectomy, tubal ligation). Plans may also have specific requirements in terms of duration of fertility and exclusion criteria for IVF concerning ovarian reserve testing or age.

Rebecca commentsOne of the biggest mistakes I made in my family building journey was making ‘assumptions’ about my husband’s and my insurance plans. These assumptions, NOT FACTS, guided some of our initial decision making processes regarding treatment. Those errors in judgment wasted precious time, and most likely were financially costly. As a wiser and more seasoned patient, I would advise that one take as much precaution and care in learning about her/his insurance coverage, as one does with obtaining information about her/his treatment options. Work with the fertility provider’s billing staff regarding your plan and benefits as soon as you begin consulting with your RE.
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