There are many variables for which fertility treatments fertility insurance covers, but this Q&A helps cut through the confusion
This is part 1 of a two-blog series, with the second blog addressing insurance coverage for IVF.
“How much will this cost?”
“Can we afford treatment?”
“Will my insurance cover anything?”
These are questions we answer every day when we help patients through the infertility journey. Concerns about the cost of infertility care can add stress to the challenge of facing infertility. In the past, few insurance companies provided any benefits for infertility treatment. That has changed over the last several years with an increasing number of companies providing benefits for their employees.
Having access to insurance coverage for infertility care can be a huge relief for patients. However, there are unique issues that accompany having insurance coverage for treatment that are different from insurance coverage for other medical conditions. Let’s talk about the ups and downs of dealing with insurance coverage for fertility treatment by posing questions we hear from patients.
My policy shows I have fertility insurance coverage; can you tell me today what specific infertility treatments my plan covers?
Every insurer has unique characteristics about their coverage plan. So the short answer is, in some cases we can tell patients at the same time as their initial visit that they have coverage for various types of treatment, but in others the carrier wants to review the medical records to confirm that based on the medical history, they will cover the infertility treatment.
Some examples of this scenario where the insurer wants to review records before they confirm if treatment is covered can include:
- They want to see how long the patient/couple has been trying to conceive.
- They want to see what prior treatments have been used.
- They want to know if there are conditions present that may cancel the fertility benefits (such as history of vasectomy or tubal ligation).
- They want to see results of preliminary testing, which is performed after the initial visit.
This information is reviewed at a patient’s initial consultation and then submitted to the insurer. Once the insurer reviews that, they provide a summary of what is covered and what is not.
Simply put, verification of infertility benefits is NOT the same as verifying coverage for a surgical procedure. There are many components of the clinical case that the insurer requires us to submit and for them to review before they will tell us what is covered.
How long will it take to learn what fertility treatments my plan will cover?
This too varies among insurers. Some insurance plans have case reviewers specially trained in infertility who evaluate the information we submit and quickly provide a response to the case within 3-4 days. Others require an extended time and it can take 2-3 weeks before we get final verification of benefits on all of the procedures that have been recommended.
To further complicate matters, some insurance companies do not have representatives who are fully trained in infertility procedures and care. This can make the process more difficult to complete as they may deny coverage for treatments that are clearly indicated based on the policy coverage. This then requires our team to submit appeals and sometimes do a peer-to-peer review (our TRM physicians speaking to an insurance company physician) to review the case and appeal on behalf of the patient … again that whole process takes time, usually a few weeks.
Another interesting challenge we’ve faced this year is that some companies have recently added insurance coverage for fertility treatments, but have not fully decided within their own companies exactly what they will cover within the range of all fertility benefits. An example of this is when egg donor or sperm donor cycles or gestational carrier cycles are used.
If we run into a situation where the company and insurance carrier cannot give us clear answers on what they will cover for the patient, all we can communicate is what the company tells us – and it is impossible for us to get an accurate quote for the patient until the company makes internal decisions. We’ve seen this take several months in some cases depending on the company.
I don’t have fertility insurance benefits. Will I know my fertility treatment costs before I start treatment?
Yes. TRM will provide you detailed estimates on your recommended treatment before you begin the cycle.
I don’t have fertility benefits, but my insurance paid for ultrasounds during testing; why won’t they pay for my ultrasounds now that I’m in treatment?
Insurers determine whether they will pay for a service based on the procedure that is done (in this case, an ultrasound) and on the diagnosis code used for the procedure. There are situations in which the same procedure is covered in one visit and not in another – and it all relates to the reason for the visit.
For example, if the reason is that the patient (male or female) is undergoing testing to determine why they have a fertility problem, then we can assign a code that is a “diagnostic” test code to the visit. But once a patient is taking medication or undergoing exams/ultrasounds for the purpose of achieving pregnancy, if there are not fertility treatment benefits, then we cannot file for coverage of the service because this is coded as a “treatment” visit.
My insurer states I can only transfer one embryo at a time for them to cover the cost of an embryo transfer. Why do they get to decide how many embryos I’m allowed to transfer? Can I transfer more than one if I want?
Insurance companies want to help you have the lowest risk possible in your pregnancy, both for your health benefit and your child’s. But they also want to help ensure that the lowest amount of money is paid for healthcare costs during your pregnancy. We know that babies want to have moms all to themselves. Moms and babies do best when one baby is growing in the uterus at a time.
While pregnancy rates are higher when more embryos are placed in the uterus, the chance that you WALK HOME FROM THE HOSPITAL WITH A HEALTHY BABY is higher if we only put in one embryo at a time.
So, it’s important that we change the definition of “success” from “pregnancy” to “healthy baby delivering at full term and going home from the hospital.”
Most patients and couples have no idea just how expensive pregnancies with multiples can be. While costs range among patients, the estimated cost of pregnancy and delivery for a singleton (one baby) pregnancy is around $21,000 (paid by insurers and the patient to the OB-GYN and hospital for care). The estimated average cost for twin deliveries is around $105,000 and for triplets, over $400,000.
At TRM, we adhere to the regulations that insurance carriers put on the recommended number of embryos to transfer. We have these discussions well before the in vitro fertilization (IVF) cycle ever starts so that if a patient isn’t comfortable with our recommendations, if need be, they can seek a different clinic that may consider their request.
My insurer tells me I need to see a “Center of Excellence” for care: What does that mean?
Insurers study the success rates of IVF centers. They want their patients to have access to care at centers that deliver outstanding care, have high success rates and low complication rates. Encouraging patients to utilize centers that have strong track records means that they have to pay less for care, because they know those centers tend to get patients pregnant faster, in less numbers of treatment cycles. Less treatment makes for a happier patient too.
Insurers tend to select one center in various regions as their preferred “Center of Excellence” and they direct all patients to that center. Sometimes this can mean you have to drive a bit for your care if the center is in a nearby city, but the advantage is often that you have more fertility benefits if you use a Center of Excellence. For example, if the lifetime benefit is $10,000, they may give up to $15,000 if a patient uses a Center of Excellence.
TRM is a Center of Excellence with the four major insurance carriers in this region, Blue Cross Blue Shield, Aetna, Cigna and United. We are also the only center partnered with Progyny in East Tennessee.
Does having fertility insurance benefits affect how quickly I can go through treatment?
Yes, it can. There are several reasons for this. First, the verification of benefits to provide the IVF quote takes longer (see item 1 above). Second, we usually have to get an authorization prior to starting EACH cycle. We cannot request authorization for multiple cycles all at the same time. If we start treatment before an authorization is in place, they will not pay.
Take an IVF cycle for example; this can require three separate authorization procedures just for one cycle, from beginning to end:
- An authorization for testing.
- Once that is complete, an authorization for the IVF stimulation and retrieval cycle and embryo creation.
- Once that is complete, an authorization for the frozen embryo transfer cycle.
Each submission has a turnaround time that ranges from days to weeks, and we are at the mercy of the insurer.
Another scenario that can complicate the timeline is among patients whom we recommend complete more than one egg retrieval at a time, prior to undergoing any frozen embryo transfers. Patients who are over age 35 and would like to have additional embryos for future sibling attempts often choose this option. In this example, the patient goes through a stimulation and egg retrieval, then immediately preps for another stimulation and retrieval. And this continues with back-to-back stimulations until the desired number of embryos is attained. In the case of insurance coverage plans, we cannot get the authorization in the required time to plan for immediate back-to-back stimulations, so patients may have two to three months in between retrieval cycles, which lengthens their overall treatment.
To bypass this problem, some patients will elect to use their benefits for the first cycle and pay out of pocket for the 2nd or 3rd stimulation and retrieval so they can do the best and fastest medical treatment rather than having to wait to start care. Our TRM team can explain this option to you further if you are in this situation.
This all sounds so complicated, and I don’t have the slightest idea how to understand my coverage or how to start planning for payment for my cycle. Will TRM help me through the process?
Absolutely! We have highly experienced, dedicated insurance specialists with over 30 years of experience working with insurance companies. We will provide you with instructions on what to do each step of the way. And if we hit an obstacle, we’ll help you understand how to get around it. We cannot solve every insurance problem, and when problems arise, we share your frustration with the process. But you can trust that we do all we can to help you through it.
Insurance coverage for fertility is a wonderful benefit – understanding the ins and outs of your plan and having patience in the process help make the experience more tolerable. If you have questions about your plan’s fertility treatment coverage and want to schedule a consultation with our providers,