Understanding Insurance Coverage for Fertility Costs

Understanding insurance is a complicated process. Understanding fertility costs, coverage, and benefits is even more involved and may leave patients feeling overwhelmed. We hope by providing information which explains some of the details and variations of infertility insurance we can reduce one aspect of the stress in our patient’s life.

An important concept to understand regarding insurance coverage is that the state lived in determines what medical treatments must be covered by any insurance provider. The state decides (mandates) what the minimum benefits are that must be provided by any insurance company operating in that state. In the state of California, fertility coverage is not a mandated benefit, therefore employers do not have to offer this benefit in the insurance plan they provide.  

Who decides what is covered?

Insurance benefits are determined by one’s employer. An employer (or a spouse/partner’s employer) contracts with an insurer (i.e. Blue Cross, Aetna, United Healthcare) to provide services at a group rate. To use an example, let’s say that Sally works for Oracle and has Blue Cross as the insurance company (the insurance “underwriter”) providing her benefits. A PFC patient works for Google, and also has Blue Cross as their insurance company. However, having the same insurance company does not mean they have the same plan. Oracle may offer their employees one plan with Blue Cross, while Google may opt to offer a completely different plan with Blue Cross. These differences could mean that our patient has fertility benefits, and Sally does not. Sally may have a co-pay of $10 for all her office visits, while our patient’s is $25. Benefits provided by the same insurance “underwriter” vary according to the company that contracted the coverage. Patients will need to understand the specifics of their individual insurance plan.

Typically, employees are able to choose a plan from options provided by their employer. Their employer should have a brochure from the insurance company listing the different plans. These plans are limited to what the employer has chosen to offer, and everyone in the company who is eligible for insurance gets the same brochure. 

Once an employee signs up with a specific plan, they receive a packet which contains a copy of their coverage of benefits or evidence of coverage (EOC). This document describes all the benefits they are entitled to under the plan. The packet may also include a summary of benefits. The summary of benefits is not the place to look to determine the extent of benefits. The summary of benefits may indicate that coverage includes 50% for negotiated rates of fertility treatment. However, it is important to read all of the details to understand what “fertility treatment” really includes. With careful reading of the evidence of coverage (EOC), including the “limitations and exclusions” section, patients may discover that procedures for IVF, IUI, and injectable medications are excluded benefits. Therefore “treatment” for this policy means diagnosis only (any appointments or procedures to determine the cause of problem), and any oral medications necessary.

What is “In Network?”

An insurance company often sets parameters detailing which physicians an employee can see. If they have an HMO (Health Maintenance Organization) plan, their primary care physician belongs to one of the many medical groups in the Bay Area. The medical group with which the primary care is associated (such as Mills Peninsula, Hill Physicians, Alta Bates, Marin IPA, Brown and Toland, etc.) is the “medical group” which is administering the HMO health plan for the insurance “underwriter” the company has selected. This means that the patient’s insurance only covers them when they see the doctors/specialists who belong to the same “medical group.” Additionally, only their primary care physician or gynecologist can refer them to a specialist or request prior authorization for them to see the specialist. They may not refer themselves. Currently, Pacific Fertility Center is contracted with Brown and Toland Medical Group and Mills-Peninsula Medical Group for HMO plans only.

If a patient has chosen a PPO (Preferred Provider Organization) plan, they are still limited to a certain network of physicians (the “preferred providers” in their PPO). Usually they do not have to have a referral to see a specialist within that network, regardless of the specialty. They may self-refer. However, to access their fertility benefits some PPO plans may require them to inform them first by pre-registering. Depending on the type of PPO coverage they have, it may be possible to self-refer to a specialist who is not in their proscribed network. They would then be going “out of network.” Typically the patient would pay a higher percentage of the cost of seeing a physician who is “out of network.” It is best for the patient to contact the customer service phone number listed on the back of their insurance card and request access to their fertility benefits. In addition, they must tell them whether these services will be provided by an “in network” or “out of network” physician. Insurance companies have instituted an increasing number of guidelines regarding fertility. For some, one must notify them first, or they will not reimburse. For others, one must complete specific testing to be eligible for their benefits.

So, let’s look at some examples to help explain the differences between an HMO plan and a PPO plan. For the HMO, let us assume that a patient’s insurance coverage is with Healthnet and they have selected the HMO plan. Their primary care physician is Dr. Smith, who is part of Mills Peninsula Medical Group. The patient has a very painful bone spur on their heel. Dr. Smith determines that they need to see a podiatrist (foot doctor) and then writes a referral to see Dr. Jones, a podiatrist in the same medical group as himself.  Dr. Jones is the only podiatrist in their medical group, therefore if they wish to use their insurance benefits, he is the only podiatrist they can see. If they wish to see a different podiatrist, Dr. Brown, they would be a private pay patient at Dr. Brown’s clinic and their insurance would not be applicable. 

If a patient has a PPO plan, this process is different. They would not need to get a referral from Dr. Smith, but could instead self-refer (no paper required) and choose to see Dr. Jones. If they decided not to see Dr. Jones but wanted to see Dr. Brown instead, they would have to determine if she was in the same network. 

Let’s assume that Dr. Brown is not in the provider network associated with the patient’s PPO plan. She is “out of network.” Depending on their plan, they may have “out of network” benefits. If they do, they will have coverage to see Dr. Brown, but will pay a higher percent of her charges than if they had gone to Dr. Jones. Depending on the practice, one may have to pay in full for services and submit the bill to their insurance for reimbursement. If their plan does not include “out of network” benefits, they will not have any coverage for Dr. Jones and will have to pay the entire fee.

The office staff of the doctor chosen usually will know whether the physician is in the patient’s PPO network or medical group. If they are unable to determine whether a certain physician is in or out of network, call the medical group or insurance company. If they want the most updated information from their insurance company, provide them with the tax ID number of that physician or practice. Doctors do change facilities and groups, and it takes the insurance companies some time to catch up with these moves. The best way to discover whether or not a particular doctor is in one’s network is to give the customer service person at their insurance company the doctor’s tax ID number. One should be able to get this number by contacting the doctor’s office. Front desk staff should be able to provide this information. If not, ask for the office manager.

What do “dx” and “trx” mean?

Once a patient has determined that they have some type of fertility coverage, their next challenge is to discover the extent of that coverage. Their plan should indicate whether they have only diagnostic (“dx”) benefits or whether benefits for treatment (“trx”) are also included. Diagnostic coverage means the testing necessary to determine the reason for the patient’s problem. Diagnostic benefits may include consultations, blood tests, semen analyses, ultrasounds, hysterosalpingogram (HSG) and things of that nature. Treatment coverage is for resolving the issue. Treatment coverage can vary widely by plan. One plan may include oral medications only, while another plan may include Intrauterine Insemination (IUI) - also referred to as Artificial Insemination (AI) - or In Vitro Fertilization (IVF). It is important to note that some options, such as treatment for sex selection when no fertility issues are present, will not be covered because these treatments would not be considered a “Medical Necessity.”

Finally, just because one has coverage does not mean there will be no cost. One’s benefits may “cap” at a certain amount. This means that a patient’s insurance carrier will pay up to a certain amount toward their services (dx or trx or both), but anything more than the predetermined “cap” amount will be their responsibility. It is also possible for the payment process to be reversed. The patient would have to pay a certain amount first, and only after they have reached a certain limit, do their benefits begin.

If a patient’s benefits are provided through an HMO, their co-pay can add to their expenses. Many times with fertility treatment this copay amount is more than the total fee for other physicians. Their copay may be as much as 50%.  One should be aware of this amount prior to their appointment.

Is Pacific Fertility Center Considered “in network” with HMO’s or PPO’s?

PFC, located in Northern California's San Francisco Bay Area,  is contracted with two medical groups that administer HMO plans. The first is Brown and Toland Medical Group (BTMG) and the second is Mills Peninsula Medical Group (MPMG). If a patient’s primary care physician belongs to either of these groups, they must receive prior authorization from the medical group to use their benefits here. If they have a PPO, or an HMO administered by a medical group other than these two medical groups (such as Hill Physicians, Alta Bates, etc.), any benefits they may have would not be applicable here. PFC does not participate in any PPO “network.” We would be “out of network” providers for anyone except those who are with BTMG or MPMG HMO.

For patients who do have BTMG or MPMG as the medical group administering their HMO, please note that it does not matter whether their insurance company is Aetna, BlueCross, Cigna, United Healthcare, Healthnet, Great Western or any other. A medical group, such as Brown and Toland, can work with many different insurance companies. Regardless of the insurance company, they will need written pre-authorization before we can make an initial appointment here. A patient’s primary care doctor or obstetrician/gynecologist submits this initial authorization request using an “infertility worksheet,” and should request an authorization for two CPT codes: 99205 for the consultation and 76830 for the ultrasound. Once we receive the authorization, we can make their appointment and establish them as our patient. Once they are a patient of ours, we will then be able to submit all subsequent authorization requests to BTMG or MPMG for further diagnostic testing or for treatment.

For patients who have PPO plans, they will be a private-pay patient here and pay for all services in full, up front. If they have “out of network” benefits, PFC can “courtesy bill” their insurance company for the appointments for which they have paid. We help save them the hassle of retaining all their receipts and completing claim forms by submitting that information for them. However, they should call the member services number on the back of their card and alert them of their plans to undergo fertility treatment. They may need to pre-register to qualify for any reimbursement. They will need to tell them that they are planning to use an out of network physician, as they may not ask. With the appropriate notification made, when their insurance company receives our billing they will reimburse the patient according to the coverage that their employer purchased, at their “out of network” rate. By law, their insurance company has from ninety (90) days to one full year to reimburse them.

Using This Information to Choose an Insurance Provider

Some potential patients may not have insurance coverage provided through an employer. Instead, they have purchased medical coverage for themselves. It is important they are aware that it is not currently possible to purchase fertility insurance for oneself through a private provider. Therefore they will not have any fertility benefits.

For those with insurance plans provided by their employer, they will need to choose a plan. Hopefully we have given readers an idea of how to make an educated decision. One will need to become their own advocate. Let’s look at an example: open enrollment is available. Now is the time to change insurance. The choices are: Kaiser, Blue Cross HMO, Cigna PPO or United Healthcare (UHC) PPO. Even though all these plans are being offered by their employer, they may not all provide the same fertility coverage. In order to determine the coverage each plan provides, they must consult the Evidence of Coverage, specifically the paragraph noting Exclusions.  It is only by determining what procedures/medications are excluded that the employee will be able to confirm the specifics of their fertility benefits. They may not have access to the paperwork noting the exclusions, as they have not signed up with the plan yet. They will not get any help from the insurance company; they do not reveal information of the details of coverage until the employee is a participant. Therefore, they will need to take advantage of their employer’s Human Resources Department. The HR person or department should be able to provide more details on the plans they are offering.

We want each patient to make an informed decision regarding their insurance plan. Don’t automatically assume that because we are contracted with BTMG that one will get the best fertility coverage with Blue Cross HMO. Although considered out-of-network if a patient has Cigna PPO, they may have out-of-network treatment benefits with Cigna which include IUI with injectable medications, compared to only diagnostic coverage through Blue Cross HMO (BTMG). It pays to do one’s homework.

HMO Medical Group: Important Addendums

Kaiser’s plan differs from the HMO plans provided by other underwriters (Aetna, BlueCross, etc.) If one chooses Kaiser as their provider, their benefits are only applicable at a Kaiser facility with a Kaiser physician. They will not have coverage if they go outside Kaiser. Some Kaiser employees may have infertility riders that allow them to access In Vitro Fertilization benefits outside the Kaiser system.

Sometimes the medical group itself has set up separate guidelines for accessing a patient’s fertility benefits. The medical group can make decisions that limit access to their coverage. If this happens, it may be something one can appeal. For example, a lesbian couple may be limited because their medical group requires six in-office (gynecologist) inseminations before they will authorize a referral to a fertility specialist. If the couple would like to use one partner’s eggs and the other’s uterus (therefore skipping straight to IVF), the couple would not meet the criteria set forth to become authorized for a fertility specialist. This might be an instance in which they could make an appeal to get the IVF they need, instead of the IUI’s they don’t need. The appeal process may be difficult and complicated, and one would need to decide if it is worthwhile. 

Try to Relax and Ask Us for Help

We hope this has been helpful. Please contact us with any additional questions. 

Our last recommendation: take a deep breath and relax. Working with insurance companies can be very frustrating. It can take time to locate someone who can answer one’s questions. It can take some effort to discover the specifics of one’s fertility benefits. Be patient; try to take things one step at a time.  We are here to assist in any way we can.