Understanding Insurance Coverage

Many insurers now offer coverage for the various stages of infertility treatment—from examinations and tests, to medical procedures and drugs. On top of that, more and more states are requiring that insurers include benefits in their policies.

Unfortunately, fertility coverage is not yet universal. So take some time to study your policy and find out if, and to what extent, you may be covered. As you do, here are some pointers to think about.

Get approval in advance — and get it in writing.

It can be very helpful to know what your policy covers before you see a healthcare provider. Your coverage may dictate what kind of healthcare provider you see, the kinds of tests you undergo, the sequence of the testing, and what treatments will be covered.

Also, try to get a commitment for coverage prior to seeing a fertility healthcare provider. This is called preauthorization or predetermination. To help you do this, we've created sample preauthorization letters as guides for you.

• Letter Requesting a Predetermination of Benefits (44 KB)
• Letter Requesting a Predetermination of Drug Coverage (43 KB)

If you have questions about what your policy covers, Fertility LifeLines™ can help you verify what benefits you may have. Call Fertility LifeLines™ at 1-866-LETS-TRY (1-866-538-7879) and a Fertility LifeLines™ benefits specialist can help you verify your benefits.

Making sense of your policy.

Look both at your medical coverage and at your prescription coverage. These are some of the things that can be helpful to look for:

• What is the definition of fertility in the contract?
• What coverage is listed?
• What procedures require preauthorization?
• Are there restrictions on the type of healthcare provider that can perform fertility services?
• What limits, if any, apply to your coverage — in terms of treatment cycles, procedures, months in therapy, etc.?
• Is there drug coverage?
• Are infertility drugs covered under the pharmacy benefit or medical benefit?
• Are there 30–day drug prescription limits for infertility drugs?

"We're not covered. No wait, maybe we are."

Unfortunately, fertility benefits aren't always clearly spelled out in policies. What's not written can be just as important as what is. In most policies there's usually room for interpretation. If you'd like help verifying your benefits, call Fertility LifeLines™ at 1-866-LETS-TRY (1-866-538-7879).

"We've been denied. Now what?"

If your claim has been denied, you may appeal. In fact, resubmissions are common. The key is to be prepared to address the issues that led to the denial. The more specific information you have, the better you'll be able to respond to your insurer's request. It can also benefit you to learn how the medical industry codes treatments. A few digits can be the difference as to whether or not you're covered!

Don't get discouraged.

Being an advocate for your fertility coverage can get frustrating. At these times, it's important to remember your rights and goals. It can also be helpful to talk with your healthcare provider in advance about your coverage.

And if you're not covered...

There may be several financing plans available to you.

Advocating for better coverage.

If you'd like to help inform the community about the importance of fertility treatment issues, here are some sample letters that advocate for coverage. One is designed to support legislation that may be before your state legislator.

The other two letters are written to help make employers more aware of the importance of adding a fertility benefit to their coverage — one you can customize to send to your employer yourself, and one that your healthcare provider can customize and forward on your behalf.

The letters can be downloaded and modified using Microsoft Word or any other text editing software. Once downloaded, insert information relevant to you wherever you (or your healthcare provider) see parentheses.

• Letter to Legislators (30 KB)
• Letter from Employee to Employer Regarding Fertility Benefits (32 KB)
• Letter from Physician to Employer Regarding Fertility Benefits (30 KB)

For more information

If you need help at any step of the way, feel free to call Fertility LifeLines™ at 1-866-LETS-TRY (1-866-538-7879). You may also wish to read a free booklet entitled Maximizing Your Insurance Coverage for Infertility (1239 KB).