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Knowing Your Benefits

Financial considerations are an important part of any medical care, especially in the decision to pursue advanced fertility treatment. Our financial counselors are at your service to explain the cost of treatment and the extent of your infertility insurance benefit prior to initiating therapy. Their expertise allows them to help maximize the insurance benefits that may be available to you through your insurance plan.

benefits verification process

We understand that dealing with the insurance companies regarding your infertility coverage might be a little intimidating initially. In order to protect yourself from incurring fees that may not be covered by your insurance plan, we strongly encourage you to obtain written verification of your benefits.

General Rules and Requirements
  • Most plans require clinical history, including physician notes, day-3 hormonal bloodwork (unmedicated), ultrasound, semen analysis, saline sonogram, or hysterosalpingogram (HSG) reports within 6-12 months before authorization is issued.
  • Plans may require patients to meet a 1-2 year history of infertility criteria before authorizing for advance treatment.
  • Plans may require patients to meet “lesser before greater” treatment criteria for advance treatment.
  • Plans may require a copy of a marriage certificate.
  • Most plans require a separate cycle authorization from medication authorizations.
  • Most plans do not cover cryopreservation and storage of embryos, eggs, or sperm.
  • Some plans offer partial coverage for donor egg treatment.
Waiting Time for Authorizations
  • Approximately 7-10 business days from submission of paperwork.
  • Authorizations cannot be backdated.


Maryland Mandate

The Maryland Insurance Article Section 15-810, "Benefits for In Vitro Fertilization," requires health and hospital insurance policies issued within the state that provide pregnancy benefits to also cover the cost of in vitro fertilization (IVF). There is a limit of three IVF attempts per live birth; not to exceed a maximum lifetime benefit of $100,000.

Criteria

For contracts that follow the Maryland mandate, benefits are provided when all of the following criteria are met:

  • The patient must be a policyholder or subscriber, or a covered spouse of the policyholder or subscriber.
  • The patient is unable to get pregnant through less-expensive covered treatments.
  • For patients whose spouse is of the opposite sex, the patient and her spouse must have at least a 2-year history of involuntary infertility or infertility must be associated with one or more of the following conditions
    • Endometriosis
    • Fetal exposure to diethylstilbestrol, also known as DES
    • Blocked or surgically removed Fallopian tubes
    • Abnormal male factors, including oligospermia, contributing to the infertility
  • For patients whose spouse is of the opposite sex, the patient’s eggs must be fertilized with the patient’s spouse’s sperm.
  • For patients whose spouse is of the same sex, there must be six attempts of artificial insemination over the course of 2 years failing to result in pregnancy.
  • IVF must be performed at a facility that conforms to the standards set by the American Fertility Society and the American Congress of Obstetricians and Gynecologists.
Exemptions
  • Regulations that took effect in 1994 exempt businesses with 50 or fewer employees from having to provide IVF coverage. [Code of Maryland Regulations (COMAR) 31.11.06.06 (B) (11).]
  • Religious organizations offering health benefits to their employees may request that carriers exclude IVF benefits; there must be bona fide religious beliefs and practices that prohibit IVF.

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