Health Insurance Coverage

Overview: Health Insurance Coverage for Infertility

It is estimated that 15% of couples struggling with infertility issues will eventually require the aid of fertility medications as well as assisted reproductive technologies, i.e. artificial inseminations and in-vitro fertilization (IVF). While many health insurance plans or managed care plans will pay for infertility tests and related services, once diagnostic testing is complete, most health insurance plans will not pay for infertility treatments.

Since costs vary greatly across clinics and from state to state, it is crucial to become familiar with your individual insurance plan. Currently there are 15 states with mandated infertility coverage that employers must provide, however plans for reimbursement vary significantly. Some states mandate a reimbursable sum per procedure, while some provide a lifetime capped sum for all infertility treatments. Still others pay a percentage after the deductible has been met. In addition, individual companies may independently elect to offer infertility benefits.

Medical Insurance for Infertility Treatments

Coverage for infertility treatment is much less common than coverage for infertility testing and diagnosis. In general, insurance plans will either not cover any infertility treatments or they will pay for part. In almost all cases, however, IVF is minimally covered, given its much greater costs than all other forms of infertility treatment. Among mandated states that do cover IVF treatments, some are more comprehensive than others. For example, the number of IVF cycles covered may vary from plan to plan. Finally, some medical insurance plans establish a lifetime maximum amount of between $10,000 and $25,000 for infertility treatments, but this again varies with each insurance carrier.

Study Your Health Insurance Plan!

It is critical to understand exactly which procedures your health insurance plan will and will not cover. It is advisable to consult with an insurance specialist that most fertility clinics provide to help you sort out all of the red tape. Be sure to ask for a copy of the insurance plan and study it yourself. If you live in a state where there is no mandated coverage, you might want to ask your employer to petition on your behalf in order to receive certain benefits.

There are also special 'nuances' provided by some financial plans, such as "shared risk." Shared risk is a program in which a couple pays for a certain number of IVF cycles independently, or "upfront," and are later reimbursed if the treatments do not result in a pregnancy. The specifics of each shared risk program also vary from company to company.

Finally, studies have shown that in cases of infertility, early intervention in the form of consulting with a fertility expert translates into lower overall infertility treatment costs since the appropriate tests are ordered immediately and precious time and money are not wasted on addressing incorrect problems or in misidentifying the cause of infertility.

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