Complicated used to be the word you used to describe your relationship status — but if you’re considering IVF and trying to figure out what the heck your health insurance will cover, complicated is probably a word you’ve been throwing around a lot lately.
Does insurance cover IVF? Are there going to be surprise bills popping up like a bad ex?
The truth is…well, it’s complicated. Amanda Garcia, practice administrator at New York fertility clinic CCRM NY, estimates 90% of employers now offer plans with some form of fertility treatment coverage, but that doesn’t always expand to IVF. And plans with IVF coverage often have criteria a prospective parent has to meet, such as an age limit or a certain number of other procedures tried before IVF will be covered.
So how do you know if your insurance will cover IVF? And what can you do to convince them to cough up the funds to finance your fertility treatments?
Making friends with your insurance company
First off, a little good news. If you’ve already been undergoing fertility treatments, you may already have found an in-network provider who takes your insurance. Maybe some (or even all) of your treatments have been covered by your health insurance company.
If that’s the case, Garcia recommends turning to the billing office of your fertility treatment center for help negotiating with your insurance company to get the IVF process covered. That’s what they’re there for. The billing office staff can:
- Go line by line through your treatment plan to ask your insurer what is or isn’t covered
- Advocate for coverage for different procedures or drugs
- Help you find loopholes in your plan, like billing ultrasounds under OB/GYN care instead of classifying them as part of fertility treatment
- Help you maximize your coverage—such as determining which procedures are best to have billed to insurance vs. paying out of pocket
Haven’t found a clinic yet, or have a doctor you adore with a billing staff that makes Cruella De Vil seem warm and fuzzy? You’ve still got this; you’ll just need to do a little more of the homework yourself. Caitlin Donovan, director of outreach and public affairs at the National Patient Advocate Foundation advises making your own calls to your insurance company to suss out what’s covered.
Some questions you ask will be specific to your area, your chosen clinic, and your situation, but Donovan says the following can really help you make your decision:
- Do I need a referral from my primary care physician or OB/GYN?
- Do I need prior authorization from the insurance company for IVF?
- Are diagnostics covered by my IVF coverage?
- What are my prescription drug benefits?
- Are there different coverages for oral medications vs. injectable medications?
- Are there different coverages if I receive medications in the office vs. at home?
- Is the anesthesiologist covered under my plan?
- Is the radiologist covered under my plan?
“Ask for their responses in writing after they talk to you,” Donovan says. “If they end up reneging, that will be crucial in an [insurance claim] appeal.”
Get on the right side of the law
It always helps when you have the law on your side to get help, and in some parts of the United States, you might be able to use state mandates to your advantage.
According to the National Conference of State Legislators, 15 states have laws on the books regarding health insurance coverage for fertility treatments:
- New Jersey
- New York
- Rhode Island
- West Virginia
Even if your state’s on the list, you’ve still got to check the laws before you call your boss and demand better coverage. They might be offering exactly what your state requires (and nothing more).
New Jersey, for example, requires insurers cover up to four egg retrieval procedures, while neighboring New York’s legislation doesn’t require much IVF treatment coverage at all. You’ll also need to brush up on any age limits and any requirements that doctors try less invasive procedures before OKing IVF. Some insurers will deny IVF coverage until a woman is 30 or even 35, and some will require a certain number of intrauterine insemination attempts before providing authorization for IVF.
Fight for your right to in vitro
After all that, what happens if your insurance company says no? Hold onto your wallet; you may still be able to get coverage.
Insurers are required to give you up to three appeals for a denied claim. For your best chance, Donovan suggests you:
- Get your doctor on board: Many doctors will get on the phone with your insurance company’s medical director to explain why they’ve chosen the treatment plan they have and why it’s so necessary for you. Others will write letters to your insurance company, including details of your medical history that might be pertinent in changing the insurers’ minds.
- Write your own appeal: This should be in addition to, not instead of your doctor’s submission. For the best results, take emotion out of it, Donovan says. Review your plan’s language and use similar language to back up your reasoning.
A little extra help
If every phone call with your health insurance company continues to make you break out in hives, you’ve still got options. There are other ways to cover your costs:
- Talk to the billing department. Yes, them again. They may be able to help you negotiate a self-pay rate if your insurance won’t cover anything or secure an IVF grant to cover some of your costs.
- Ask your doctor if they’ve got sample medications on hand to help reduce the number you have to buy.
- Friends and family may want to help support your journey. It never hurts to ask.
- Apply for help from a fertility treatment charity.
At the end of the day
It can feel like it would be easier to run a marathon without training than it is to get your health insurance company to pay for IVF. But don’t be afraid to ask for help—whether it’s asking the billing department to advocate for you or the person on the other end of the line at the health insurance company to answer your long list of questions.