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Does Insurance Cover Fertility Testing or Treatments?

The Different Types of Fertility Insurance and What Is Covered

Most health insurance plans consider maternity and newborn care to be essential benefits. However, fertility care may or may not be covered. Fertility coverage depends on what your employer chooses to offer. So, how do you know if insurance covers fertility testing or treatments? Coverage can vary depending on your employer, the size of the company and if any state fertility mandates apply.

Some plans may cover In Vitro Fertilization (IVF) but not the injection medications that women also require during IVF treatment cycles. Some plans cover treatment and medication, while other plans cover a specific number of attempts or a lifetime maximum dollar amount for certain treatments. However, there are plans that do not cover IVF at all.

To find out what fertility benefits your employer offers, your employer or insurance company should provide you with a copy of your insurance plan, including the details of benefits and coverage. You can also seek help from the financial counselor at your fertility doctor’s office, they work with your insurance company throughout the process to review your benefits in detail and keep you informed to avoid any unexpected costs.

In some cases, employers offer supplemental fertility coverage through companies like Progyny and Carrot. You can check with your employer to see if they offer any supplemental fertility coverage. These supplemental plans are fertility-specific and accompany your traditional health insurance to give you greater coverage that breaks the financial barrier for those wanting to grow their family. These plans typically give patients access to the care they need without the restrictions of traditional healthcare plans and enable patients to obtain better outcomes. With 1 in 8 couples now needing fertility assistance, employers offering fertility benefits and or supplemental fertility coverage usually have higher employee retention and overall morale among employees.

How the New York State Mandate Impacts Fertility Insurance

Fortunately, thanks to the New York State Mandate, more employers headquartered in New York are now required to offer fertility coverage. Effective January 1, 2020, New York requires all “Large Group” employers (fully insured with over 100 employees) to cover up to three cycles of IVF. The mandate also requires insurance plans to cover egg and sperm freezing when medically necessary, including, but not limited to sickle cell anemia, cancer diagnosis, and surgery for endometriosis. Unfortunately, it does not cover same-sex male couples at this time.

While this has been a great step forward in giving many New Yorkers access to the treatment they may not have otherwise been able to afford, the mandate still doesn’t apply to some employers. Some employers that won’t fall under the new mandate include those with self-insured plans, fully-insured “Small Group” plans (with under 100 employees), and Medicaid/Marketplace plans.

The good news with Medicaid/Marketplace plans is that under the mandate, although they don’t cover the cost of treatment itself, they may still cover the medication necessary for treatment which can save you thousands of dollars.

Which Tests or Treatments Could Be Covered?

Many plans cover diagnostic testing even if they don’t cover treatment. If you are under 35 and have been trying to conceive for over 12 months or if you are over 35 and have been trying for over 6 months, it could be time to see a fertility specialist. Your fertility specialist can order diagnostic tests to assess your reproductive health, check hormone levels and analyze semen for male partners. These steps will help to determine if there are any medical problems that could be hindering you from getting pregnant.
Diagnostic tests for infertility include a physical exam, imaging tests, specialized diagnostic tests, and bloodwork. Imaging tests and specialized tests look at the reproductive organs, blockages, and identifying underlying causes. Laboratory tests usually involve cultures to rule out bacteria or infection and testing of blood for hormone levels. The combination of these diagnostic tests, known as a fertility workup, will help your doctor identify any causes for infertility.

How to Check Your Insurance Plan for Fertility Coverage

To find out more about your particular insurance plan, you can go online to your insurance company’s website to check your benefits, call the customer assistance phone number located on your insurance card, speak to your company’s HR or benefits staff, or call your fertility specialist to have them check your coverage and assist you with the details. Another option is to look at your partner's insurance. Some patients switch over to their partner’s plan or “double-up” and use both plans.
If you need assistance finding out the best option, check with your fertility specialist’s financial counselor - they will be happy to check both your and your partner’s plans so that you can get the most coverage and minimize your out-of-pocket costs.

How to Use the Coverage When You Know That You Have It

Call and set up an initial consultation with a Reproductive Endocrinologist (REI) (a fertility specialist) to get started. During your first visit to Kofinas Fertility Group, a comprehensive examination will be completed—including an in-depth medical discussion and a trans-vaginal ultrasound. During this examination, you and your doctor will decide the best course of action for your individual needs.
Your first visit also includes a discussion with our Financial Coordinator to explain the out-of-pocket costs (if any) associated with your particular plan of care, the coverage available to you through your insurance provider, and additional financing options. We will be happy to assist you and answer any questions you may have.

If you are interested in talking to a New York doctor about PCOS, request an appointment with Kofinas Fertility today! Even though you may enter as a patient, we believe in building a relationship with you that goes beyond a case file. With Kofinas Fertility Group, your care is our primary concern, so get started today and step into the future with confidence. 

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