Frequently Asked IVF Insurance Questions

Please review your policy. If IVF coverage is not clearly stated, the Customer Service Department will be able to give you more specific information. You will find this phone number on your insurance card.

Not all employers have to offer IVF coverage under the NYS mandate. If your employer is self-insured they don’t have to follow the mandate. Your employer must have 100+ employees to be considered eligible.

Questions to ask your employer:

• Is our health insurance provided controlled by New York State?
• Is our health insurance plan fully insured?
• Are we part of the large group market?

If yes, you may have IVF coverage.

This question is more difficult to answer than it would seem, because it is not the insurance company, but the type of contract you have that makes the difference. IVF coverage is contract dependent. Your employer’s Human Resources representative can supply you with a copy of the health care policy which will state your infertility coverage in general.

• Your insurance company may require you to meet certain criteria or complete certain treatments before covering IVF, this is contract dependent.
• If the contract covers IVF, try to determine if there is something in your medical history that may cause them to deny coverage (e.g., tubal ligation, vasectomy, donor oocytes).

This question is more difficult to answer than it would seem, because it depends on your insurance contact. You may be responsible for your deductibles, co-insurance, or copays in accordance with your contact. Not all of your IVF services with our office may be covered by your insurance, this will be contract dependent. If a service is not covered you will be required to pay before your treatment cycle. You may have copays for blood work, which will be billed by the lab.

If you have insurance coverage, we will bill your insurance company only if we have written authorization prior to the start of your cycle. Once you have been approved to move forward with IVF our office will work with your insurance company’s prior authorization department to obtain this authorization. You will not be able to start your IVF medications without a written, approved, prior authorization from your insurance company. Prior authorization can take up to 15 business days to be approved/denied by your insurance. Without written authorization, you will be considered a self-pay patient. All self-pay patients are required to pay the entire amount for professional services on the day of the baseline appointment. We accept MasterCard, Visa, Discover, or bank check. We do not accept personal checks, cash, or American Express.

In a few cases, an insurance company will approve all cycles at once. In most cases each cycle must be approved separately. In some cases your authorization may have expired, whether you have done a cycle or not. Please let the billing staff know as soon as you decide to do a subsequent cycle, so we can get your preapproval started.

We will need complete information on both policies. If both policies tell us in writing that they will cover IVF, we must bill your insurance first, then bill the balance to your husband’s insurance. If your primary insurance will not cover IVF but your secondary will, we must have a denial in writing from the primary in order to bill the secondary. Some secondaries will accept a letter of denial, others require that we bill the primary, wait for a denial on an explanation of benefits statement, then send this statement when we bill the secondary.

If you are having an IVF cycle, we must disclose that to your insurance company when completing the authorization.

You might. Please contact whoever handles your pharmacy benefit and give them a list of the medications you will be taking. They may require information from the medical staff. Medication authorization can take up to 15 business days to be approved.

Most insurance companies do not cover cryopreservation of embryos or storage, this will be contract dependent. If you decide to freeze embryos, the first year’s storage is prorated from the date of freezing. After the first full year, your embryos will be transferred to long term storage with Reprotech. If all embryos are then thawed, any extra paid storage fees will be prorated and refunded or credited to your account as long as there is no balance on your account.

We will need an approved prior authorization for AHA in order for our office to bill this service. If AHA is not covered you will be responsible for payment prior to starting your cycle.

Most insurance companies will not cover genetic testing. Insurance companies may cover genetic testing if you/your partner or children are carriers of a genetic disease. Most insurance companies do not consider genetic testing of chromosome (PGT-A) medically necessary and age is not an indication for genetic testing. Prior Authorization will be required and self-pay fees may still apply. Please ask the financial counselors for more information.

You have the right to appeal their decision. Call their customer service department and tell them you would like to file a formal appeal. These cases usually go before their medical review board. They should get back to you in less than one month.