Insurance that covers IVF is increasingly common but it can be complicated, with essential nuances explained here
“I have insurance for IVF, so that covers everything, right?”
“Why is my insurer now saying they won’t cover what they already told me they would cover?”
“Why does my IVF insurance still require a copay for certain types of visits?”
Having insurance that covers IVF (in vitro fertilization) is a huge relief for many patients. Thankfully, insurance for IVF and other fertility treatments is growing, as more employers recognize that infertility is a condition that about 10% of their workers will experience.
Utilizing those IVF insurance benefits can be tricky, and nearly all patients with insurance that covers IVF have lots of questions. With good reason. As IVF insurance benefits grow, many insurers are just figuring out how to award benefits. Plus, the IVF procedure is really a group of medical services.
Following are the questions we are asked most often about insurance that covers IVF and our answers.
I have insurance that covers IVF, so doesn’t this mean the entire IVF cycle is fully covered?
No. IVF is a medical treatment that spans two to three months for most patients and involves 10-15 office visits, numerous ultrasounds, labs, at least two minor surgical procedures, and then up to seven days of very intricate work in the embryology laboratory creating and nurturing the embryos. There is not one medical code to file with the insurer for IVF. Rather, there are individual medical procedure codes for every step of the process.
For instance, there are 7-10 different procedure codes used just for the work involving the embryos. The insurer has to review each of these recommended procedures/codes individually and review the terms of the policy before they confirm with TRM if they will cover that portion of the recommended treatment.
How much of my IVF costs will my insurer pay?
It depends … on whether you’ve used any of your prior treatment benefits and on your deductible. Every insurer carves out different terms for their coverage. Some allocate a specific lifetime amount of benefits (for example, $5,000, $10,000 etc.). In these cases, TRM submits the recommended treatment to the carrier, the carrier reviews the policy to see if any prior treatment benefits have been paid out for the patient to other providers (for example, if the patient had any treatment before coming to TRM), and then gives a cycle cost estimate based on what treatment benefits remain.
Other plans pay for a certain number of treatment cycles (for example, one IVF cycle, or two IVF cycles, or four insemination/IUI cycles etc.) In these cases, again TRM would submit the recommended treatment to the carrier, and they would see what, if any, prior treatment has been done and then give approval for the new treatment if benefits remained. Again, they would assign a certain amount as the “cycle cost” or “patient copay” that the patient would pay to TRM for their cycle.
It is VERY important for patients to understand that there are different components of coverage – meaning there is coverage for treatment and then coverage for medications.
Medications can range greatly in cost among patients. To give you an idea of how much they can cost for patients paying out of pocket, the average IVF cycle medication costs can range from $3,000-6,000 per cycle. These fees are charged by pharmacies and are not controlled by TRM.
Some plans will cover treatment costs and medication costs separately. This means that if there is a lifetime benefit for $10,000, and there is coverage for medications separately, then the entire $10,000 benefit can go toward treatment cycles. This means the patient can undergo more treatment if needed (in general, the more treatment cycles a patient can complete, the more likely a patient will have success with IVF). Other plans cover medication costs AS PART OF THE FULL LIFETIME BENEFIT. This can have a big impact on how much money is available for treatment costs.
For example, let’s assume the lifetime benefit for a patient is for $10,000 of IVF care, and this includes the costs of treatment and medications. If the patient’s medications cost $4,000, then they would only have $6,000 left to allocate to treatment costs. In contrast, if a different patient’s plan covers $10,000 of treatment, and covers medications separately from the $10,000 lifetime maximum benefit, then the patient would have $10,000 rather than $6,000 to apply to IVF treatment costs.
Do I have to make a copay every time I come in for a visit during my cycle if I have insurance that covers IVF?
Generally the answer is no. In most cases, we collect the cycle fee (determined by the insurer) as one total fee before the treatment cycle starts. Then as the cycle progresses, we file the insurance claims with the insurer and the insurer pays TRM a few weeks later. There can be situations in which additional fees apply at the end of the cycle if we had to perform additional procedures during the cycle that were not anticipated to be needed prior to the cycle starting. Our intent is to plan for as much as we can in terms of what we think may be needed. But it is impossible to foresee every single scenario that can arise in infertility cycle treatment. Medicine is an art, not a perfect science.
My insurer told me they would cover a certain procedure but now they are saying after the IVF cycle is over that they are denying payment for that procedure; what can I do?
This is an incredibly frustrating situation that can arise in any cycle. While it is impossible to prevent this from happening in every case, we recommend doing the following steps to help protect yourself from this problem. Whenever you talk to anyone at your insurance company, KEEP A PAPER TRAIL.
- Date of the conversation or email or letter.
- Name of the employee who helped you.
- Reference number/code for the communication (the insurers keep this in most cases, and you can ask for it at the end of the communication).
That way, if they change their decision on coverage for a procedure that they previously stated they would cover, we may be able to help you appeal it. They won’t always pay, but it may help your case.
My insurer won’t pay for a certain part of IVF, but I want to include that treatment, so can I pay for it separately?
Some policies will not pay for various portions of the cycle treatment despite the doctor recommending it. An example of this might be when the doctor recommends considering preimplantation genetic testing (PGT) of embryos. If you want to include PGT and your insurer denies it, you can request a cash price estimate from us and pay that separately.
This insurance coverage for IVF is very complicated, and I need more help before I start planning for payment for my cycle. Can TRM help with this?
Yes, we can – and we help patients with this all the time! Our highly experienced insurance specialists know the ins and outs of working with insurance companies on IVF benefits. We will help you through every step and every obstacle that comes up, doing all we can to get you the benefits you are due.
Have questions about your plan’s fertility treatment coverage? Schedule a consultation with our providers.