Billing & Insurance
Health insurance coverage for infertility and IVF treatment overview
Health insurance can add to the complexities of the decisions you will have to make when choosing infertility treatment options. At RMA of Michigan, our goal is to alleviate some of that stress and help you work with your insurance company to ensure that you are reimbursed at the maximum level that you are covered.
Insurance coverage for infertility treatment including artificial insemination and in vitro fertilization varies greatly. Some insurance plans will cover nothing related to infertility services, some may pay for all of it and many are somewhere in between.
As a patient, whether you are from Michigan, Ohio or elsewhere, you can be the best advocate for yourself by thoroughly understanding your policy. It is important that you review your specific policy and understand what will be paid and what will not.
Treatment for infertility is covered by insurance much less commonly than testing is. When there is coverage for infertility treatment, it is fairly common to exclude IVF or to have a lifetime maximum benefit. We commonly see health insurance plans that have between $10,000 and $25,000 as a lifetime maximum. This caps the potential costs for the insurance carrier. In other cases, insurance will cover testing and treatment up to and including intrauterine inseminations – but they will not cover IVF – in vitro fertilization services. Sometimes the “monitoring” of the IVF ovarian stimulation (blood and ultrasound tests) are covered, but all of the more expensive IVF codes are not covered.
Resolve’s Coverage At Work Program
The extent of coverage, benefits and authorization process vary from policy to policy. It is important that you understand what is covered before you begin treatment or what the necessary requirements are to get the maximum reimbursement. The finance department can provide some general guidelines on the most common policies within each plan.
Some plans require authorizations. We encourage all patients to check the infertility benefits under your specific plan as well as confirm in-network status. Our participation with your insurance does not guarantee coverage for our services.
We are “in-network” with several leading insurance plans including:
- Aetna – Designated an Aetna Institute of Excellence™
- Blue Cross Blue Shield of Michigan – Blue Distinction Center for Fertility Care Designation
- Carrot
- Cofinity*
- HAP – HMO (excluding Henry Ford network) & HAP Preferred
- Priority Health – PPO & some POS plans
- Priority Health – HMO (Corewell Health network only)
- Progyny
- UnitedHealthcare – Fertility Solutions Center of Excellence
- WINFertility
*For Ohio patients, we do participate with Medical Mutual of Ohio if your insurance card says Cofinity on the back of it.
We do not participate with any Medicaid or Medicare plan.
When a doctor is out of network it does not mean that the insurance company will not pay for the services. If we are out of network with the plan, then the patient will usually have a higher amount of coinsurance (what they are expected to pay) as compared to if they went to a doctor that is in network. We have many patients that see us out of network. They have decided to come to us out of network because of our superior success rates, our personalized care, recommendations from friends or their doctor, or for other reasons.
If you have a non-participating insurance company, RMA will require payment up front for all services. Payment will be expected at the time of service for all non-IVF services and 2 weeks prior to the start of your cycle for IVF.
RMA of Michigan would like to emphasize the importance of reading and understanding your insurance policy, its requirements and the covered and non-covered services. Infertility benefits vary from patient to patient. We’ve put together a few key points about insurance coverage by major plans to help you manage expectations of coverage. The information provided is for informational purposes only and is not a commitment of coverage.
When pursuing insurance coverage, do not just handle it over the phone. If you simply call and ask about coverage for a certain procedure, the customer service representative may give you his or her interpretation of what he/she thinks the policy states. If you receive a verbal verification of coverage, you will not have any written documentation.
It is helpful to get any determination of benefits and coverage in writing from the insurance company. Written verification of their intent to pay is a much more effective tool than verbal if you have a challenge or must appeal. You should contact your insurance company with a request that they provide you with a written pre-determination of your exact coverage and any eligibility or requirements that must be met in order to get that service covered. You must call your insurance carrier to obtain the proper forms for pre-determination. This is something that they should provide you with as a contract holder.
Here are important questions to ask the insurance company:
- What are the specific policies or procedures that I need to follow to get infertility treatment covered? For example, do I need authorization for office visits, blood work or office procedures?
- Is there a dollar maximum associated with infertility treatment? If so, what is that dollar amount? Does the maximum include medications?
- Is there a maximum lifetime amount for Intrauterine Inseminations (IUI)?
- How many cycles of In vitro Fertilization are covered?
Waiting time for authorizations:
- Approximately 15 business days from submission of your paperwork.
Basic requirements for ART/IVF coverage:
- Most plans require clinical history including physician notes, blood work, Day-3 FSH, semen analysis, saline sonogram or HSG reports before authorization is issued.
- Requires new authorization if treatment plan converted (example IUI to IVF or vice versa).
- Plan may require patients meet “lesser before greater” treatment criteria for medications, even if procedures have already been approved.
Genetic Testing (PGD) / Comprehensive Chromosome Screening (CCS):
- Coverage is rarely provided. Patient is responsible for confirming coverage for PGD/CCS.
If insurance coverage doesn’t exist, RMA offers a multi cycle discount plan and a refund program that allows patients to pay a discounted rate for multiple IVF cycles. We also work with financing companies that can provide medical loans to help patients pay for treatment. Please call a RMA of Michigan Financial Counselor at 248-619-3100 for more information regarding these programs.
