5 Common Misconceptions When Using IVF Insurance

Historically, treatments for infertility have not been covered by most insurance plans, leaving couples and individuals on the path to parenthood with even less support along their journey. Luckily, in recent years, things have started to change and many employers are providing insurance coverage for infertility treatments that in the past would have been thousands of dollars out-of-pocket for the patient.

There are a lot of different pieces of the puzzle when working with your insurance company, and even your clinic, to make sure you are maximizing your coverage.

Below we’ll go over assumptions we’ve seen others make in the past that you should discuss with your insurance carrier to make sure you are getting as much of your treatments covered as possible while avoiding any surprise bills:

In-network vs Out-of-network

Misconception #1: “I have coverage so I can go to any clinic I want”

Doctors and clinics have their own unique relationships with each insurance carrier. Some doctors are in-network for certain insurance plans but are out-of-network for others.

This can affect how much of your treatments will be paid for by insurance versus how much you will pay yourself.

In-network: you will have more of your covered treatment paid for by your insurance

Out-of-network: insurance will cover less of your treatment and sometimes nothing at all

If you really want to work with a specific physician so much that you’re willing to go out-of-network with your medical plan, that’s totally up to you! But just be aware that your costs will most likely be higher.

If you do have a specific fertility clinic or reproductive endocrinologist that you’d like to work with, make sure to contact your insurance to confirm whether they are an in-network provider for your plan (check the clinic name and the doctor name, just in case). Your clinic may also be able to provide this information to you as well but it doesn’t hurt to double-check yourself!

Which treatments are covered

Misconception #2: “I have infertility coverage so any treatment my doctor chooses is covered”

If you already know what treatment you’re moving forward with, such as an IUI or IVF cycle, then definitely check to make sure that the specific treatment is covered by your plan. Just because you have an in-network doctor doesn’t mean that every treatment under the care of that doctor will be covered.

For example, some medical plans might cover IUI but not IVF. Or some might have coverage for both IUI and IVF but there is a minimum required number of IUI cycles you have to undergo before your insurance will cover an IVF cycle. This caveat is important to know about as you might not be able to jump straight to IVF even if that’s what your doctor recommends!

These types of limitations exist on some health plans and not on others. You can contact your health insurance carrier directly with treatment coverage questions and they should be able to tell you what is covered.

It often helps to get a list of procedure codes (CPT codes) from your clinic for your treatment & your diagnosis code as well because. Your health insurance representative may need to plug these codes into their system to say for sure how your insurance plan will process the bills.

You can also find coverage information in your summary of benefits document, which describes the coverage you have for your plan for different treatments.

Common IVF procedures that are not covered by insurance

Misconception #3: “IVF is covered so all procedures that are part of my IVF cycle will be covered too”

There are so many different procedures that can fall under a treatment cycle and it won’t always be the same for each person or even for each cycle.

IVF cycles for example have office visits, blood work, ultrasounds, an egg retrieval, embryological procedures, embryo freezing, embryo transfers, etc. And that’s separate from even considering the different medication types. 🙀

There are procedures that some patients with IVF coverage might undergo that aren’t covered by insurance. This is sometimes due to the fact that certain clinics are using a new technology that is not yet considered to be standard of care by insurance plans.

IVF procedures that are commonly not covered by insurance are:

ICSI
PGT-A / PGS
PGT-M / PGD
genetic counseling
genetic carrier screening
embryoscope
co-culture
assisted hatching
storage costs for embryos/eggs/sperm

These are a few examples that might apply to your plan but not all possibilities.

Make sure to check with your insurance whether these procedures can be covered or whether you would be paying these out-of-pocket.

Your treatment plan might not include any of these but it's good to know your coverage ahead of time in case you needed to have on of these services for your IVF cycle.

Your cost may differ compared to someone else with the exact same insurance plan

Misconception #4: "My coworker has the same insurance as me and paid nothing, that will be the same for me, right?"

Right? WRONG! Do not use your coworker’s personal account of what they paid to estimate what you will pay to your clinic for treatment. There are many different reasons why someone with the exact same insurance plan as you might not pay the same amount for the same treatment.

Different CPT & Diagnosis codes

When your clinic sends in a claim to insurance for a service they performed, they typically need to include procedure codes (CPT codes) for what was done as well as a diagnosis code (ICD-10 code) specific to why they did this procedure for you. You and your coworker might have different CPT codes and diagnosis codes that cause the insurance plan to pay differently.

Different treatment protocol

Your treatment protocol will likely not be identical either. For example, you may need more monitoring appointments or may need a surgical hysteroscopy while they didn’t. Your treatment is unique to you and there are different labs and procedures your physician might be ordering for you that your friend didn’t have, or vice versa!

Different number of dependents on your plan

You might have a family plan for your health insurance while your coworker is on an individual plan. The number of dependents added on a health plan can sometimes affect how much a person pays to insurance even for their own covered treatments.

Already met their deductible or max out-of-pocket earlier in the year

Another important detail is that your coworker may have been regularly using their insurance earlier in the year and had already met their deductible or max out-of-pocket by the time they started infertility treatment, which would definitely affect how much they would pay for covered services.

Hasn't seen any bills in the mail yet

The difference might even come down to the fact that your coworker hasn’t seen any bills from their clinic yet! Insurance claims can take weeks or even months to process so perhaps it hasn’t yet been determined what they will owe.

It’s probably well-intentioned for a coworker to try to give you an idea of cost but take this with a huge grain of salt and do your own research based on your specific situation as it likely will not be the exact same.

Being double-insured doesn't always make things easier

Misconception #5: "My infertility insurance isn’t as good as my husband’s employer plan. I'm covered on both plans so I’ll tell my clinic to skip using my employer’s insurance and just use his instead."

This could be an entirely separate article and probably should be, so we’ll keep this short and sweet.

If you have your own health insurance through your employer (primary insurance) and you are also listed as a dependent on your partner’s separate health plan through their employer (secondary insurance), you have a coordination of benefits scenario.

Unfortunately, you can't just give your secondary insurance info to the clinic and have them skip right over your primary. You are required to submit claims to your primary insurance first to use any coverage you have there. After, anything that was not covered or any cost-share you paid to your primary plan can be submitted to your secondary plan to see if they will cover anything further for you.

Your clinic will be familiar with this situation and can assist you in the process but know that the process of submitting first to your primary plan and then to secondary insurance will take longer than if you were just using one health plan. The main reason for things taking longer is that you have to wait for the first insurance plan to process your claims before you can resubmit to your secondary.

Also remember that you’ll be paying any deductible, coinsurance or copays due to your primary plan first for whatever they cover. Your secondary plan will likely have it's own deductible, co-insurance and/or copays due as well. Your secondary plan may be able to help you out by applying any cost-share amount you paid to your primary plan to count as paying your secondary plan's deductible and coinsurance as well, so that you're not effectively paying two deductibles in a plan year.

Coordination of benefits can be tricky and might even require you to pay quite a bit for services upfront and get reimbursed. So if you plan to use both health plans, do make sure to contact your secondary insurance plan to understand what they will need from you in order to coordinate benefits and help you get coverage.

These are our top 5 suggestions of details to check with your insurance company to help you identify any potential out-of-pocket costs and avoid any unpleasant surprises.

Have any of these ever tripped you up at your clinic? What wasn’t covered under your plan?

🕵️‍♀️ Ready to start looking for a fertility clinic? Head to our clinic search to compare options in your area & learn more about each provider & their IVF success rates.