Insurance Policies - Part 1 (Overview)
Plans vary considerably in coverage for infertility. Some plans cover diagnostic procedures only and some cover diagnostic procedures and treatment, but only specific types of treatment may be covered.
There are 3 main categories of insurance policies:
1. Private Indemnity
Any Doctor of Your Choice May have a deductible:
• Usually 80%-100% reimbursement. 0%-20% of the Physicians' fee are your responsibility.
2. Preferred Provider Organization (PPO)
Services Rendered by a Network of Physicians Contracted with the Insurance Company
• Deductible Must be met before 80%-90% insurance reimbursement of their usual and customary fees.
• Patients responsibility: 0%-10% of the usual and customary fees.
• Services provided by physicians outside of network are not subject to usual customary fees.
3. Health Maintenance Organization (HMO)
a. Basic HMO
Services provided through Physicians controlled by the HMO
• Services must be requested by the Primary Care Physician and authorized by the HMO. Co-pay ranges from $5-$20 per service. Some plans allow 50% co-pay for infertility services.
b. Individual Practice Association (IPA)
Services provided through direct contracts with independent physicians.
• Services must be preauthorized by IPA. Co-pay ranges from $5-$20 per service.
• Some plans allow for additional deductible, additional co-pay amounts, and additional waiting periods before reimbursement.
Know your coverage:
• Get a copy of the contract and/or the summary plan description. Plans usually list services which are included and services which are excluded from the plan.
• "Infertility services excluded" means neither diagnostic procedures nor treatment is covered.
• "Infertility covered, but no artificial insemination, assisted reproductive technology covered", usually means diagnostic procedures, surgery or monitoring of drug therapy may be covered.