Insurance Information for Infertility Treatment
Many insurance companies provide coverage for testing and treatment of infertility. Understanding how insurance works can be very frustrating and time consuming. When dealing with infertility, this problem usually gets worse. Each insurance carrier may have programs with infertility benefits, but these benefits can be modified depending on the group contract or an individuals selected medical group. Because of this level of complexity, it is impossible to make any generalized statements about what benefits you may have. With some of the tips provided on this page, you can begin your own investigation into the potential benefits you may have.
When you are evaluating your infertility benefits, it is important to understand several important distinctions. Insurance benefits may cover diagnostic testing, treatment, or medications. Your policy may cover some or all of these options. It is very common for insurance companies to cover diagnostic testing but not treatment. Treatment costs will be paid out of pocket so you will want to select a clinic with straight forward pricing to avoid any hidden costs to you. You will also want to understand if there are any co-payments that must be made and if there are any limitations to your benefits. We have prepared a list of questions that you should ask your insurance provider.
Questions to Ask Your Insurance Carrier about Infertility Insurance
- Do I have diagnostic infertility coverage to allow the doctor to find the cause of infertility?
- Do I need a referral to visit Dr. (name your regular doctor) for an initial consultation?
- Do I have infertility treatment coverage so that the doctors can perform
intrauterine insemination (IUI), if it is recommended?
- Do I have coverage for in vitro fertilization (IVF)? If so, does it cover include:
intracytoplasmic sperm injection (ICSI), cryopreservation (freezing of
embryos); storage of frozen embryos, transfer of frozen embryos in later
- If this is covered, does my policy require prior authorization for these
- If I have coverage, what is the maximum infertility benefit?
- If my policy does not cover infertility treatment, does the policy cover office
visits, lab work and ultrasounds during a non-covered treatment cycle?
- Does my policy include injectable medications? If so, does my policy require
prior authorization for those medications?
- Do I need to use a specific lab for these procedures?
- California infertility insurance coverage: are there any insurances plans that cover IVF?
Some insurance companies can only give you information if you provide them with the appropriate billing codes, called CPT codes. Some of the most common CPT codes are listed below.
Intrauterine insemination (IUI)
Sperm prep for insemination 89261
IVF vitro fertilization (IVF)
Intrauterine embryo transfer 58974
Oocyte (egg) retrieval 58970
Intracytoplasmic sperm injection (ICSI) 89280
Cryopreservation of embryos 89258
Storage of embryos 89342
Frozen Embryo Transfer (FET)
Thawing of cryopreserved embryos 89352
Preparation of embryo for transfer 89255
Intrauterine embryo transfer 58974
2 wk Lupron Kit J9218
Gonal F S0126
California IVF: Davis Fertility Center, Inc. has contracts with numerous insurance carriers. The contract terms are often specific to the particular medical group to which you are assigned as well as any employer specific contract inclusions/exclusions that may be placed on your benefits. You should contact your insurance carrier to find out more information using the questions provided above. We will also contact your insurance provider for verification of benefits. The clinic may be told something completely different and it will always be in your best interest to verify your own covered benefits.
How the Clinic Can Help
The clinic staff will perform a verification of benefits and discuss the findings with you. We can try to give you reasonable estimates for treatment services based on the information obtained. We will not likely be able to give you an exact treatment estimate as every contract is different and in most cases we are unable to know the amount to be paid by the insurance until after the claims are submitted. While this is often very frustrating, you may contact your insurance carrier and request more detailed information. The clinic and staff are not responsible for establishing the benefits that are provided under your plan and can not continue to query or debate coverage with individual health plans. We will do our best to give you the most accurate estimate possible and any additional inquiries should be directed to your insurance provider.
The clinic can often help you to develop a strategy to maximize your health benefits. In some cases it may be more cost effective for you to pay for services out of pocket and submit a request for reimbursement to your insurance carrier. We can help provide you with guidance on the most cost effective approach. In cases where you do not have any treatment benefits, you will want to take advantage of our global, or package pricing. These options allow you to know exactly what the treatment costs will be and are often very competitive with clinics in the Sacramento area, including Kaiser.
The California IVF Difference
Our team of insurance specialists are headed by Terri Perez. Terri brings many years of experience working with insurance companies from many different angles. She has worked with doctors offices, hospitals, insurance companies, and medical groups. Her expertise has helped our clinic and patients utilize the medical insurance benefits to their maximum potential. In many cases, Terri has held meetings with the insurance providers in the area and provided education and training with regards to infertility treatments. Compare this to the approach that is taken by other clinics where your insurance benefits are not accepted by the clinic and you are asked to pay for services in advance and bill your insurance on your own. This quickly becomes a nightmare and you will not likely receive your maximum benefit. At California IVF: Davis Fertility Center, Inc. our experienced billing staff strives to utilize your insurance coverage to your advantage.
We work with each patient to try and maximize their benefits. We go to the extent of verifying insurance coverage, explaining benefits (which many patients appreciate since this has not usually been done for them), obtaining authorizations and guiding the patient through the whole process. Many of the patients who come from other centers express their gratitude for this service. They state they never received this type of service anywhere else. They are also surprised to hear about our very affordable cash pricing for non covered services.
When insurance coverage is not an option for your treatments, we offer straight forward pricing that is easy to understand. We do not like hidden costs and will do what we can to make sure you understand the costs of any treatments that are recommended. The pricing for services not covered by insurance may represent lower amounts than your insurance estimate. This is due mostly to the significant overhead involved in processing and submitting insurance claims. With advanced payments, the savings is passed on to the patients.
HMO, PPO, EPO, and More
Health insurance can be tricky to understand with so many abbreviations. We provide services to contracted HMO’s, PPO’s, and EPO’s. We are also happy to provide services to all insurance plan members who have the flexibility of going to a non-contracted provider. The majority of health plans do not cover infertility treatment therefore it does not matter if the member goes to a contracted provider or not.
HMO – Health Maintenance Organization. Under an HMO, patients are usually required to see a a provider within the network of physicians. If specialty care is needed outside or outside of the network, patients will need an authorization from their primary care manager (PCM). Your OBGYN can often submit a request to your PCM for a referral.
PPO – Preferred Provider Network. A PPO will often allow self referral to a specialist without the involvement of the primary care manager. The co-payments associated with these types of plans are often much higher. If the PPO network does not have a network specialist, the plan usually offers coverage for an out of network provider.
EPO – Employer driven contract. The best example of an EPO is the health plan provided to Sutter employees. Sutter manages their own health plan and insurance benefits. California IVF is contracted as a provider for Sutter EPO beneficiaries.
California IVF: Davis Fertility Center, Inc. is also a member of the various Sutter networks including Sutter Physicians Alliance (SPA), Sutter Independent Physicians (SPA), and Sutter Specialty Network (SSN).
Patients with an HMO plans administered by Medical Groups that are not contracted with our facility can request to change to any of the Northern California Sutter Medical Groups. This can be done by contacting their insurance company and requesting to change to the Sutter Medical Group as their Primary Medical Group (PMG). If the request is submitted prior to the 15th of the month the change should be effective the first of the following month. We are happy to assist in this process.
California Infertility Insurance Coverage
Under the California infertility health insurance laws, insurance companies must offer infertility insurance coverage for diagnosis and treatment of infertility. California does not require insurance companies to provide health insurance coverage, but they must offer the option for infertility benefits. Employers are not required to include infertility insurance as part of their employee insurance plans. Individuals may request the addition of the infertility testing and treatment coverage, usually at an additional expense to the individual. Sometimes, lockout periods will apply to prevent someone from signing up and using the benefits without an initial waiting period. Each health plan can be different, even policies from the same insurance provide can be different between two different employers. Use our Questions to Ask Your Insurance Carrier about Infertility Insurance as a guide to help you discuss your options with your human resources manager or insurance broker.