Referrals, deductibles, lifetime maximums, eligibility requirements, preferred pharmacies – the fine print on insurance policies can be dizzying – but understanding what to look for when it comes to your fertility insurance coverage can save you both time and money. Take Sharon and Jason for example.
The couple was married in 2000 and started trying to have a child the next year. They were both sure they wanted a big family, so they thought they should get started right away. Sadly, Sharon’s first pregnancy ended in miscarriage. She remembers, “It didn’t worry us that much because we knew it happened to a lot of people. Plus, we got pregnant again, so we thought everything was fine.” With that pregnancy, they had a son, and a year later, they started trying for a second child.
This time, things were different. “We went about a year and a half without getting pregnant, so we started to worry that something might be wrong,” says Sharon. Their ob/gyn recommended Clomid, an oral medication that would help Sharon ovulate regularly.
After several months without a positive pregnancy test, they were feeling discouraged. “We are very active in our Jewish community, and everyone around us was having their 2nd or 3rd child, so it was really hard on us having these disappointments every month,” Sharon says.
They decided to get more aggressive. “We thought we should be more proactive and see a fertility specialist but were not sure where to start.” says Sharon. “We also had lots of questions. Did we need to have a referral from our ob/gyn? How were we going to pay for treatment?”
Turns out they did not need a referral from their insurance company and they couple started saving to pay for treatment. At their first appointment with Dr. David Saffan at Shady Grove Fertility’s Annandale office, their financial counselor gave them some great news – their insurance actually covered their fertility treatment.
But just what did “having coverage” mean?
Call Us and We Can Walk You Through the Process
Healthcare policies vary from person to person and from company to company, therefore it’s hard to determine the exact coverage you will have. When in doubt, call Shady Grove Fertility’s New Patient Center to get an idea if you will need a referral or not.
When new patients book an appointment at Shady Grove Fertility, you will be asked for your insurance information so that our financial team can check your insurance policy for coverage after your initial appointment. “Most patients have coverage for the initial consultation,” says Nick Dominy, one of Shady Grove Fertility’s financial counselors, “but they may have a deductible that they need to meet before coverage kicks in, or they may need a referral. In that case, they need to know who the referral has to come from and allow some time for it to be processed.”
“Our prescreening insurance benefits team will check your coverage, and we’ll meet or talk with you to review the results after your first appointment,” says Nick, “but it’s really best if you have some knowledge of your policy. That way, we can compare notes after your appointment. If we received the same information from the insurance company, it’s great. If we got different information, then our team can go back and find out why.”
Sharon agrees that calling ahead of time would have helped. “In our case, we just assumed we didn’t have coverage, and we came in and told them that. The financial counselor said that she would verify anyway, just so we had the denial in writing. Lo and behold, it came back that we did have coverage. That was when we pulled out the benefits booklet that Jason’s work had provided and started to look into the details.”
Verifying Diagnosis and Testing Benefits
“Ninety percent of patients have some level of coverage for their initial consultation,” says Nick. “After your consultation, your physician will likely require a complete fertility evaluation and it’s good to know what will be covered by insurance.”
By the time Sharon and Jason started their diagnostic workup, they had confirmed what the financial counselor told them and knew that their testing would be completely covered.
“If you are curious to know if your insurance company will cover your fertility evaluation, you should call and ask if diagnostic testing is included in your policy,” Says Nick. He cautions, though, that there are policies that have what’s called “a complete exclusion” on fertility services. “That would mean that anything billed by a fertility center, like Shady Grove Fertility, would be denied.”
What are Treatment Benefits?
After diagnostic testing, patients return to review the results with their physician and decide on a treatment plan. At this appointment, patients meet with their financial counselor again. Now, they are able to talk specifics about treatment costs and how their insurance can or can’t be used.
“Our tests didn’t reveal any major fertility issues,” says Sharon, “so we were diagnosed with unexplained infertility.” Dr. Saffan suggested they start treatment with a low-tech treatment option called Intrauterine Insemination or IUI.
Sharon adds, “Once we knew what our treatment would be, we called the insurance company ourselves to verify what the financial counselor had told us about treatment coverage.”
Nick says this is a great idea because patients need to understand all the details about their coverage. “Seventy percent of patients have some level of coverage for treatment, but you should never accept a simple yes or no answer about treatment coverage. An insurance company will rarely cover everyone 100% of the time. It depends on their review of your case and the claims that are submitted and – in many policies – a lot of additional details.”
For example, some policies will pay to treat underlying medical conditions that cause infertility but won’t pay for fertility treatments like IUI or IVF. Sometimes, there are criteria that the patients have to meet in order to be eligible for treatment coverage. “They might have to be married or never have had a sterilization procedure like a vasectomy,” says Nick. “We were really worried that we wouldn’t qualify for treatment coverage because we already had a child,” says Sharon. “So, we asked specifically about that. It turned out that it didn’t matter because we have what is called ‘secondary infertility’ and that was covered.”
Policies with a lifetime maximum can sometimes be confusing for patients. “Patients need to know what contributes to the max,” warns Nick. “Are all services including diagnostic testing? Do medications count? Or is it just treatments that contribute to the lifetime max and is the max defined by the number of cycles the patient is eligible for or a maximum cost of services?” Some patients will have a limit on the total number of cycles they can use while others may have a dollar point that they cannot exceed.
Sharon and Jason discovered that they were covered for up to 6 IUI cycles and 3 IVF cycles of treatment per live birth. They used 3 of their 6 IUI cycles and did not get pregnant. Dr. Saffan recommended moving to In Vitro Fertilization (IVF) as a next step. That triggered the couple to sit down with the financial counselor again to make sure they would be covered for the new course of treatment. “We needed to get approved for the IVF before we started,” says Sharon.
Nick says needing authorization for treatment is common and patients are often frustrated by how long it takes. “Patients are anxious to get started with treatment. That is completely understandable, but sometimes it takes a while for the insurance companies to send us the authorization. I might be calling back and forth with them for a few weeks; sometimes providing additional documentation to support the treatment will help get the approval needed to move forward with treatment.”
Sharon and Jason got their approval and did a cycle of IVF. They got pregnant and even graduated from fertility care, but then, tragically, they lost the pregnancy at 17 weeks. “That was a really rough period for us,” recalls Sharon. “I had had a miscarriage before, but this was so much worse because I had gone through all this treatment and made it through my first trimester.”
After Dr. Saffan did some additional testing and made changes to her treatment protocol, Sharon and Jason tried again with another round of IVF. This would be their 2nd cycle of treatment out of the 3 IVF cycles they had covered, so they were nearing the maximum allowed by their plan. Happily, this cycle was a success. Sharon got pregnant again and carried the pregnancy to term without any problems. Their second son was born in 2006.
“We were thrilled about having another child,” says Sharon. “Even better, we had a whole bunch of good embryos from the cycle that were frozen, so we knew we had a chance to have another child.”
Two years later, they came back to Shady Grove Fertility to try for a third child. Their policy allowed for a new set of cycles for this child. They did a Frozen Embryo Transfer (FET) cycle, but it didn’t take, so they tried again. On FET cycle #2, they got pregnant. In 2008, they had another baby boy.
Verifying Medication Benefits
After their first FET cycle, Sharon and Jason found out that medication benefits can have different rules than treatment benefits. “During all our previous treatment cycles, my medications were covered,” says Sharon. “Then, after our first FET cycle, we got this big bill for medications, and we were confused. When we called the insurance company, it turned out they wouldn’t cover the meds for the FET cycles – only for the IUI and IVF cycles.”
Medication benefits are separate from diagnosis and treatment benefits in most insurance policies. Often, insurance providers even rely on separate companies to handle medication benefits for their policyholders. Shady Grove Fertility’s financial counselors can’t provide information about medication coverage.
“We don’t dispense medications to patients, so we can’t verify medication coverage, however we help patients identify the correct information for their pharmaceutical benefits verification.” says Nick. “Also, the pharmacies can verify your coverage in the same way we do for treatment. In fact, the specialty pharmacies that do fertility medications usually have dedicated insurance specialists that will help you get the most out of your coverage.”
It’s also a good idea to check with your nurse to find out if there are any medication discount programs offered from pharmaceutical companies.
What if Insurance Doesn’t Cover Your Expenses?
It doesn’t happen often, but sometimes patients are better off using one of Shady Grove Fertility’s financial programs than using their insurance benefits.
Nick explains, “One example might be if you have a low lifetime max for treatment, like $2,000-$5,000, and medication costs contribute to the max. Or, sometimes after our initial benefit review, we find that insurance will not cover treatment at all. In those cases, it might be better to do the Shared Risk program and use your insurance coverage for medications.”
The Shared Risk 100% Refund Plan gives you up to 6 cycles of IVF and the related frozen embryo cycles for the cost of about 2 IVF cycles. If you don’t take a baby home from the hospital, your money is 100% refunded. Nick adds, “There are also other programs like the Multi-Cycle Discount that might better fit the needs of our patients.”
Another common scenario is when policies have a cycle max, meaning they will cover a certain number of cycles, regardless of what kind of treatment those cycles are. In this case, you might want to pay out-of-pocket for less expensive treatment cycles like IUI or FET so that you can save your insurance benefits for more costly cycles like IVF.
“This is where your financial counselor can really help because he or she knows our financial programs and can sit with you and compare your specific coverage against out-of-pocket costs,” says Nick.
Knowledge is Power…and Money
Every insurance policy is different and they have an incredible range of rules and procedures. That’s why Shady Grove Fertility verifies coverage for every single patient and encourages every patient to call for him or herself as well. By using the help of our financial counselors, you can get the most out of your coverage and reduce the stress you may have about affording treatment.
Though Sharon and Jason started out in the dark about their policy, they quickly got up to speed and it proved to be a great blessing for them. “We are so happy with our family. Having three boys means a lot of chaos and craziness, but its wonderful chaos and we love it.”
For more information or to schedule an appointment with one of our physicians, please speak with one of our friendly New Patient Liaisons by calling 888-761-1967.