If you are planning to undergo fertility treatment in the next year, you’re probably already thinking about what it will cost and whether your insurance will cover the bill. If you have an employer who provides coverage for fertility treatment, you’ll want to make sure you make the right choices during open enrollment to maximize the possible benefits you could receive.
Benefits are Employer-Driven: Get Help from your Human Resources (HR) Department
To find out the benefits available to you, request a copy of your benefits summary from your employer. Even if you have the same plan, benefits and out-of-pocket expenses may change from year to year.
Contact your HR department or your employer’s benefits coordinator if infertility isn’t listed on the Benefits Summary. Calling the insurance company directly usually does not help because your employer is the one who chooses the details of the plans they will offer. The customer service team at the insurance company often doesn’t have access to those details until members subscribe to a particular plan.
Pick the Plan that’s Best for Your Family.
Picking the right plan can be confusing. SGF’s team of experienced financial counselors is available to help you understand the policy jargon and provide clarification that might make the selection process easier.
If You are Selecting an HMO Plan, Don’t Forget to Select a Primary Care Physician (PCP)
This step may seem unrelated to the care a physician in a completely different practice—and even specialty—provides, but when it comes to accessing coverage within an HMO plan, you will need a referral in the majority of cases. That referral comes from your PCP of record. If you have not selected a PCP at the time of enrollment, the insurance provider will either select a physician for you—one that you may not know—or leave it blank. Either option can make obtaining the needed referral prior to your appointment difficult to obtain.
Ask the Right Questions
Insurance policies are full of jargon and fine print, but those details can make a big difference in the coverage you receive. For example, some policies will pay to treat underlying medical conditions that cause infertility, but won’t pay for fertility treatments like intrauterine insemination (IUI) or in vitro fertilization (IVF). Asking the right questions can help you better understand what a future plan may cover:
- Are the initial consultation and diagnostic testing covered?
- Is IUI covered?
- Is IVF covered?
- Is there any coverage for the medications associated with these treatments (sometimes referred to as “injectable” medications)?
- Are pre-existing conditions excluded? If so, what qualifies as pre-existing?
- Do we have to meet any special medical criteria to use the benefit?
- Is there a maximum benefit amount? Is it a dollar amount or a number of cycles? Is it annual or lifetime? What counts toward the max—diagnostic testing, medications, or just treatments?
- Are there deductibles, co-pays, and/or co-insurance?
- Do we need a referral in order to see a fertility specialist?
- Do we need prior authorization for consultation, testing, or treatment?
Be Aware that Your Existing Plan May Change
Even if your insurance company stays the same, your employer may purchase different benefits affecting your plan for the coming year. Because of rising costs, companies are frequently increasing deductibles and requiring more co-insurance from employees. It’s always a good idea to re-check your benefits even if you think you want to stay on the same plan.
Sign Up for an FSA or HSA Account
To help cover your expenses, it may be beneficial to enroll in either a flexible spending account (FSA) or health savings account (HSA) if your employer provides one. These accounts are funded with pre-tax money deducted from your paycheck; you may use it to pay for medical expenses not paid for by insurance, such as deductibles, co-pays, treatment, and medications.
When planning the amount of money to add to your FSA or HSA, keep in mind of the administrative rules that surround these accounts. For all of these guidelines, please refer to IRS publication 969.
Check In-Network vs. Out-Of-Network Benefits
It’s important to find out if the plans being offered by your employer are accepted by SGF.
Even if none of the plans being offered by your employer are accepted by SGF, you can still use your benefits if you have an out-of-network option on the plan. Most plans will list benefits for in-network and out-of-network on the Benefits Summary. There may be different rules for using benefits out-of-network and there is usually a higher cost associated with treatment for the patient.
Once Open Enrollment is complete, there are a few additional steps to take to ensure you don’t experience a delay in treatment starting with the New Year. For patients who are, or may, change insurance at year-end, please note the following important points:
Notify SGF as Soon as Your Coverage Changes
It is important to notify your financial counselor as soon as your insurance information changes in order to prevent delays in treatment. It takes time to verify benefits—sometimes several weeks—and we do not want to see any delays in your treatment. Please note that the earliest insurance plan changes can be verified for 2019 is the beginning of January, once your insurance provider has updated its system.
Re-verification of Benefits is Required before Starting Treatment
Your new or updated insurance plan will not allow SGF to verify your benefits until they are in place with your insurance company. This does not happen until the start of the new calendar year or later. You may have proof of eligibility given to you by your employer, but until your benefits are actually loaded in your insurance plan’s system, we cannot access or obtain fertility benefits or authorizations on your behalf. Timing of new treatment cycles for the early week(s) after the first of the New Year have proven from experience to be particularly problematic.
Confirm Your Referral is Current and Up-to-Date
The majority of HMO plans require a current referral from your PCP before covering any visits. You can obtain a new referral by contacting the PCP’s office directly.
Consider the Time Required to Obtain Authorizations
Several insurance plans require providers to obtain referrals and prior authorizations on behalf of patients before they can start any course of testing or treatment. These authorizations in some cases can take up to a month to receive and can delay treatment start dates for patients. If you wish to start a treatment cycle in the first few weeks of January with your insurance benefits, our financial team will need to obtain the necessary prior authorizations before you can begin to cycle. Please keep in mind that we must work with—and through—your insurance plan to obtain benefits and authorizations, and there may be delays on their part in processing insurance changes and registering new enrollees.
SGF Accepts Most Major Insurance:
Approximately 70 percent of our patients have some coverage for infertility treatment and 90 percent have coverage for their initial consultation. View our list of insurance networks accepted by Shady Grove Fertility. Please note that each state accepts different insurances.
We encourage you to determine what benefits you will receive based on your insurance plan before you begin treatment. You may have out-of-network benefits that will allow you to be seen by our physicians.