Navigating your insurance benefits at Shady Grove Fertility (SGF) is an important step in your fertility journey. Understanding your coverage can help minimize out-of-pocket expenses and streamline your treatment process. This guide provides an overview of how to effectively navigate your insurance benefits and highlights common insurance codes related to fertility treatments.
Coverage for fertility diagnostics and treatment can vary significantly depending on your insurance provider, employer plan, and state of residence. Review the plans SGF accepts on our Accepted Insurance + Fertility Benefits page to get a sense of where your coverage starts.
Understanding your coverage for fertility diagnostics and treatment
Insurance coverage for fertility diagnostics, testing, and treatment isn’t one-size-fits-all, and the details can shape both your care plan and your budget. Before starting treatment, it helps to know exactly what’s covered, what isn’t, and where your out-of-pocket costs are likely to fall.
- Initial consultation and treatment coverage: Approximately 90% of SGF patients have insurance coverage for their initial consultation, and about 70% have some coverage for infertility treatment.
- Review your benefits summary: Obtain a copy of your benefits summary from your employer to understand what is covered under your plan. Be aware that benefits and out-of-pocket expenses can change annually. Pay attention to both in-network and out-of-network benefits, since coverage levels and costs often differ between the two. Plan type matters as well—a PPO and a high-deductible health plan (HDHP) can cover fertility care very differently, even through the same employer.
- Flexible spending accounts (FSA): Consider utilizing an FSA or Health Savings Account (HSA) to cover medical expenses not paid by insurance, such as deductibles, co-pays, and treatments not covered.
Verifying your benefits
- Contact your HR department: If infertility coverage isn’t listed in your benefits summary, reach out to your Human Resources department or benefits coordinator for clarification. They can provide detailed information about your specific plan. Your HR team can also tell you which fertility benefit vendors or third-party administrators, such as Progyny or Carrot, are included in your plan, when you become eligible to use them, and whether additional family-building resources, like adoption assistance or surrogacy support, are offered.
- Consult SGF Financial Educators: SGF’s Financial Educators are available to explain treatment costs and help maximize your insurance benefits before starting therapy.
- Contact your insurance provider directly: Your insurance company can walk you through the specifics of your plan, including coverage limitations, prior authorization requirements, and any exclusions related to fertility care.
Gaining coverage
- State fertility insurance laws: Some states have laws requiring health insurance coverage for infertility diagnosis and/or treatment. Check if your state has such mandates, as this can impact your coverage.
- Employer-sponsored plans: Even in states without mandates, employers may offer plans that include infertility benefits. Discuss available options with your HR department.
Additional financing options
When insurance, state-mandated coverage, or an employer-sponsored plan doesn’t cover the full cost of care, additional financing options can help close the gap. We offer several programs designed to make treatment more manageable and predictable.
- Payment plans and financing: Manageable financing, offered through CapexMD, provides 0% financing for the first six months of treatment, with loan terms up to 84 months. Grant programs, including the Tinina Q. Cade Foundation and SGF-exclusive grants, can also help offset costs for qualifying patients.
- Shared Risk 100% Refund for IVF: This program covers up to six IVF cycles for a fixed fee, excluding medications, with a full refund if treatment doesn’t result in a pregnancy or if you choose to step away. Some exclusions apply.
- HSA/FSA funds and discount programs: An HSA or FSA typically can’t be used for insurance premiums, but it may cover co-pays, deductibles, lab tests, over-the-counter pregnancy tests, ovulation predictor kits, breast pumps, and prenatal vitamins. Additional discount programs, such as the Multi-Cycle Discount for IVF and the Military Discount, may further reduce costs depending on eligibility.
Common insurance codes for fertility treatments
Familiarizing yourself with common insurance codes can facilitate discussions with your insurance provider and help ensure accurate billing. Here are some frequently used codes:
- In vitro fertilization (IVF) procedures:
- 58970: Follicle puncture for oocyte retrieval
- 58974: Intrauterine embryo transfer
- 89250: Culture of oocyte(s)/embryo(s), less than 4 days
- 89254: Oocyte identification from follicular fluid
- 89268: Insemination of oocytes
- 89272: Extended culture of oocyte(s)/embryo(s), 4-7 days
- Artificial insemination (AI) and intrauterine insemination (IUI):
- 58322: Artificial insemination; intrauterine (IUI)
- 58323: Sperm washing for artificial insemination
- Assisted reproductive technology (ART) procedures:
- 89251: Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture
- 89255: Preparation of embryo for transfer
- 89258: Cryopreservation; embryo
- 89261: Sperm isolation; complex prep (e.g., Percoll gradient, albumin gradient) for insemination or diagnosis
These codes are based on the Current Procedural Terminology (CPT) system and are used for billing and insurance purposes. Discussing these codes with your provider and insurance company can help clarify coverage specifics. This list is regularly updated, and other codes could be billed for your treatment plan. Please speak with your Financial Educator for more information. This list is not a comprehensive list of all codes that may be billed but can serve as a helpful guide.
Additional tips before starting fertility treatment
- Pre-authorization: Some insurance plans require pre-authorization for certain fertility treatments. Ensure all necessary approvals are obtained before starting treatment to avoid unexpected expenses.
- Keep detailed records: Maintain copies of all communications with your insurance company, including pre-authorizations, denials, and appeals.
- Appeals process: If a claim is denied, don’t hesitate to appeal. Provide additional documentation and work closely with your healthcare provider to support your case.
By proactively managing your insurance benefits and understanding the associated codes, you can navigate the financial aspects of your fertility treatment more effectively. For personalized assistance, contact SGF’s Financial Educators who are ready to help you through this process.
Editors Note: This post has been updated for accuracy and comprehensiveness as of September 2026.
