How do I get my IVF covered by insurance in the United States?

By Jennifer “Jay” Palumbo

When you know you’re going to need fertility treatment like in vitro fertilization (IVF), one of your first questions should be how to get IVF covered by insurance, especially when insurance in the United States can be lacking!

One of the best first steps is to know and understand your health insurance benefits. In the below, we’re going to offer advice on what to look for, how to understand your existing coverage and how to best advocate for yourself and your fertility treatment.

First, find out if you already have coverage

The first step to knowing your coverage and how to get IVF covered by insurance is to request your “Summary of Benefits” to find out if your benefits already include in vitro fertilization. Your summary of benefits may also be referred to as a “Benefits Package” or “Explanation of Benefits”. If you have insurance through your job, you can either contact your Human Resources department to get the most up-to-date copy, or if you’re self-insured, you can contact your insurance company directly. Once you get a copy, you need to review your benefits to see exactly what your coverage is. Typically, coverage for fertility treatment falls into one of the following categories:

No Fertility Coverage

Coverage Only for Diagnostic Testing: Some insurances also may cover some related treatment if there’s a general health condition such as Polycystic Ovarian Syndrome or Endometriosis, that happens to impact fertility.

Coverage for the Diagnosis of Infertility but Not the Treatment: In addition, some insurances may even specific which health care provider you need to be diagnosed by such as an OB/GYN, Reproductive Endocrinologist and/or a fertility clinic.

Limited Fertility Coverage: It’s important you read this in detail as limited treatment could mean they allow timed fertility cycles with a medication called clomid, or intrauterine insemination (IUI) but not IVF

Full Coverage: Again, even with full coverage, insurances typically have a limit on how many cycles of IVF you can do, or they have a monetary limit to how much fertility treatment you can do. For example: They may offer $10,000 per lifetime maximum for fertility treatment

While it’s your responsibility to know and understand your benefits, you can speak to your Human Resources department, insurance company or, if you already being treated by a fertility doctor, most clinics have a financial advisor that can potentially advise you.

If you have existing fertility benefits

The good news is your insurance offers fertility benefits! Still, you want to make certain that there are no hiccups and you make every effort to ensure your coverage runs smoothly. How to get IVF covered is ask for a copy of your IVF coverage in writing or request a written statement confirming coverage from your insurance company.

Next, while undergoing treatment, pay careful attention to what your diagnostic code is or what is being used at it can impact your coverage. When you spoke to your insurance company and confirmed how to get IVF covered by insurance, you ideally discussed the diagnostic code necessary to properly process your in vitro fertilization cycle. Therefore, you should play close to attention to how your clinic is submitting your paperwork before they submit it to make certain that it’s correct. It’s incredibly difficult after claims have already been submitted to try and fix it and if the wrong diagnostic code is used, it can impact your coverage.

Also, if your insurance company limits the amount of IVF cycles you can have, be certain to clarify what counts as a cycle. Should you have a cancelled cycle, how would they handle that, and would that count against your maximum lifetime limit?

If you have little (to no) coverage

If you feel comfortable, advocating on your own behalf can make all the difference when it comes to how to get IVF covered by insurance. Especially when it comes benefits that are provided by your employer. According to a survey done in 2006 by Mercer Health and Benefits and commissioned by RESOLVE – The National Infertility Association. They discovered that 65% of companies offered infertility treatment in direct response to employees requesting IVF and/or fertility coverage.

This means that if you’re open to advocating for yourself and sharing your fertility struggle, speaking to your Human Resources representative, sharing with them this infographic created by RESOLVE would increase feelings of company loyalty, employees would miss less work and would recommend the company as not only a great place to work but also view it as “family friendly”. If your HR Team saw IVF benefits could be an investment, it could help not just you but other co-workers who are dealing with infertility.

If your insurance is not through your company (or you prefer not to speak to your HR person), you can call your insurance company directly and request for either a form where you can request how to get IVF covered by insurance, if you can get documentation from your doctor supporting why IVF is medically necessary for you to have a family (including any diagnostic codes, tests, etc. explaining why your reproductive endocrinologist is recommending in vitro fertilization) or if you can file an appeal or grievance on how to get IVF covered by insurance.

You can also provide them studies such as the one done by the National Institutes of Health that found that patients who have access to fertility coverage end up saving their insurance companies money. The research in this study shows that when employees do not have fertility benefits, they transfer more than one embryo, resulting in twin or triplet pregnancies. This results in higher risk pregnancies and/or NICU costs due to premature deliveries. When patients have IVF coverage, they can transfer one embryo, which means a singleton pregnancy, which tends to result in less complications, thus saving money and protecting the health of both the mother and child.

How to be your own patient advocate

Whether you decide to be an advocate on how to get IVF covered by insurance and/or fertility benefits in general, there are ways you can be a patient advocate for yourself and your own treatment:

Speak to your clinic about any IVF clinical trials that you may qualify for that cover either the cycle or any of the medication you would require.

Ask your reproductive endocrinologist about whether they recommend Pre-implantation Genetic Testing for Aneuploidy (PGT-A), which can help increase the chances of having a healthy baby and decrease your chances of a miscarriage. This test is typically not covered by insurance or fertility benefits but can help increase the chance of a successful outcome of your IVF cycle, which in the long run, can help save you money.

Keep copies of any of the money you’ve spent on fertility treatment or any related doctor’s appointment and ask your accountant if it can be filed under “medical” when you file your taxes for that year.

Investigate if any of your Flexible Spending Account (FSA) or your Healthcare Savings Account (HSA) can be used towards IVF for that year.

Fertility treatment itself can be overwhelming

Adding how to cover affording IVF can add an extra layer of concern to a potentially stressful situation. What’s important to remember is you do have so many avenues to explore, options you can pursue and, should you feel comfortable sharing your infertility journey with those who are in positions to help, you can advocate for yourself to increase access to care not just for your own treatment but for those who will come after you!

Have you used your insurance cover for IVF? Or have you been refused cover of fertility treatment? What was your experience? We would love to hear from you at mystory@ivfbabble.com or on social media @ivfbabble