Understanding which fertility benefits your insurance provider offers (if any) can be a daunting process. Even when your fertility clinic verifies coverage, it’s important to call your insurance company to confirm all the details and ask any additional questions you may have.

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As you begin exploring your options, it’s easy to get overwhelmed by the cost of fertility treatment and question whether you will even be able to afford the care you need to make your dreams come true. 

It’s no secret – insurance policies are notoriously difficult to interpret. There are several places to turn for help understanding your coverage:

• Your employer’s human resources (HR) department
• Your fertility clinic’s finance or billing department
• Your health insurance provider’s customer service department

In this guide, we will walk you through the most important questions to ask in order to determine your level of coverage for fertility-related testing and treatment.

Note: Some states (including CT & NY) even mandate fertility coverage from employers.

Now that you know where to find support understanding your policy, the next step is knowing what to ask. That’s why we’ve compiled a comprehensive list of questions to ask your HR department and insurance provider before beginning fertility treatment. 

If your insurance policy does not cover infertility, head straight to your employer’s human resources representative with the following questions:

Is there another plan I can switch to that does include infertility?

If switching plans is an option, make sure to clarify if there are any restrictions on using your new fertility benefits. Some insurance companies require a certain amount of time to pass before dipping into benefits like infertility coverage.

Are there any ways to supplement coverage for my fertility journey?

Some employers offer fertility supplementation or reimbursement separate from their health insurance. You may need to purchase an insurance rider on top of your current plan, or a separate package through another provider.

Are there any company policies that can support me as I seek fertility treatment?

If you discover you have no opportunity for fertility coverage supplementation, there’s a possibility your employer could help you in other ways! For example, a more flexible work schedule, more paid time off or sick days, etc.

Pro tip: Download RESOLVE’s Coverage at Work Employee Toolkit to learn how to approach your employer and push for expanded fertility benefits.

Some insurance companies will only cover your treatment if it’s administered by certain clinics. Typically, the preferred fertility clinics are ones that report to the Society for Reproductive Technology (SART), a third-party information source that publishes yearly clinic statistics, though your insurer may have other requirements to keep in mind.

How do you define infertility in order to grant coverage?

Some insurance plans require a specific amount of time of “exposure to sperm” (i.e. trying to conceive without assistance for opposite-sex couples) or other specific diagnoses before allowing access to extended fertility coverage. 

Other questions to ask:

• Is there an age limit for fertility coverage?
• Is pre-authorization required before beginning treatment?

Do I have to meet a deductible before my fertility coverage kicks in?

Ask about all the office visits you’ll have, and if those copays will be applied to your deductible, should you have one.

Is all fertility testing covered?

Fertility testing is an essential part of the process and must be performed before any treatments are started. Are diagnostics like hysterosalpingography (HSG), saline sonogram (SHG), and genetic carrier screening covered? 

Other questions to ask:

• Does my policy require the use of a specific, contracted laboratory?
• Will any lab charges at my fertility clinic be covered?

What specific fertility treatments do you cover?

Some insurance policies will not cover anything more than ovulation induction medication. Some will cover a wide range of fertility treatment pathways. Make sure to get a detailed list!

Is there a particular order for procedures I’ll need to follow?

Many insurance policies require you to start your journey with a less invasive treatment option (such as ovulation induction or IUI) before they will cover IVF treatment. Also ask: Can I do IVF first if my doctor recommends it?

Do you cover fertility medications?

Medication is a big part of most fertility journeys, and can cost thousands of dollars – so you’ll want to be sure they are covered. Also ask: Will I need to use a specific pharmacy?

Do I have any yearly or lifetime maximums on procedures or spend?

Some plans place a cap on how much fertility treatment will be covered in a given period of time. For example, your lifetime allotment might be three IUI cycles and one IVF cycle, or perhaps one IVF cycle per year.

Some plans will not put a cap on the type of procedures but will instead grant you a certain monetary stipend to be used on fertility care within a given amount of time. For example, you could be given a $25,000 lifetime allotment.

Other questions to ask:

• How many rounds of IVF am I allowed?
• What specific treatments do you cover?
• What if I make it through my allotted coverage?
• Is there an add-on package I can purchase?

Will I have a copay for office visits?

And will all of my visits have the same copay, regardless of the purpose?

You’ll be at your fertility clinic quite a bit between getting blood work, ultrasounds, or diagnostic testing – or simply a consultation with your doctor. Be sure to ask this question so you don’t rack up unexpected charges at every single visit.

Reminder: A copayment (copay) is a set fee you pay at a doctor’s appointment or when you pick up a prescription. Some plans have $5 copays, others are $25 or higher. 

Do you cover preimplantation genetic testing (PGT)?

PGT refers to a series of screening tests that can identify genetic abnormalities in embryos created through in vitro fertilization (IVF), and is especially important for hopeful parents who are carriers for genetic disorders, such as cystic fibrosis. 

If I need ICSI in an IVF cycle, will it be covered?

Intracytoplasmic sperm injection (ICSI) is a hyper-focused fertilization method where an embryologist manually places a single sperm inside an egg. ICSI can be essential to IVF success in cases of male factor infertility, for example.

Do you cover cryopreservation?

Most fertility patients end up needing to freeze their eggs or embryos, so you’ll want to budget for those costs if they’re not covered. A good follow-up question to ask: Is there any coverage or reimbursement for the costs of keeping specimens frozen year over year?

How will we communicate from this point forward?

It’s important to know whether your insurance company will correspond directly with your fertility clinic or if they will be contacting you directly with results, approvals, or denials.

Here’s a quick summary of the five most common ways to finance a fertility journey:

1. Out-of-Pocket

Have some money saved up or available to put towards treatment? This might be the moment you use that surplus.

However, for many people, paying out-of-pocket is simply not an option, with fertility treatment costs ranging from a few thousand dollars to $180,000+ (for pathways such as gestational surrogacy). 

2. Financial Grants

Financial grants are a great way to help supplement the cost of fertility treatment – you might even find some that cover the entire process (testing, medication, and procedures).

Note: Grants typically have stipulations (ex: must use a specific clinic or live in a particular state in order to qualify for application). Always read the fine print!

3. Medical Loans

Medical loans are another option for some people. However, it’s critical to note that these are essentially out-of-pocket, as you’ll ultimately end up having to pay the loan back (plus interest).

Still, loans might be a better option than just swiping a credit card for every bill, since you can negotiate a predetermined interest rate and payback period for a loan.

4. Fertility Clinic Plans

Often times, a fertility clinic will have financial options that either discount their services or assist you in paying over a particular amount of time. At Illume Fertility, we offer a variety of Opportunity Plans that help make the journey more accessible. 

And then there’s that option we all hope for…

5. Health Insurance 

As you now know, some health insurance plans will either partially or fully cover the costs associated with fertility treatment.

However, one insurer may include a stipend for fertility medication, while a different insurer may give you a lifetime monetary allotment – the options vary widely. That’s why understanding what your policy offers upfront is so vital. 

Knowledge is Power

It’s important you do everything you can to understand your insurance coverage and give your family-building dreams a chance to come true.

While spending time on the phone with insurance and HR representatives may take some effort now, asking these necessary questions will pay off in the long run – and could save you thousands of dollars!

Have more questions about your fertility journey? Reach out to our team!