Navigating insurance coverage and employer benefits can be a bit daunting, especially when wanting to better understand the potential costs associated with building a family. A few important steps to understand coverage and out-of-pocket expenses include:
- Look at your insurance company’s explanation of benefits documents
- Call your insurance company and ask a series of questions for greater clarity
- Verify coverage with your fertility clinic to get a better understanding of costs specific to that clinic
Review your explanation of benefits
This is a document that summarizes the costs of health care services by breaking down the co-pay, deductible, coinsurance or non-covered amounts. This breakdown also shows what services (e.g. preventative care versus inpatient hospitalization) will cost since it varies depending on the type of provider visit or healthcare needs you may have.
Many employers have an explanation of benefits package that can be found via the company portal or through reaching out to the company’s Human Resources department. This document will also often have a breakdown of other employer-provided perks and incentives that may impact how you navigate your health and wellness, and what decisions you make around building a family. Looking through this explanation of benefits is a good starting point before calling your insurance company to better understand your coverage.
Contact your insurance company by phone
Below, we’ve provided you with a list of questions to have on hand when you call your insurance company. While an explanation of benefits document may give you a good idea of what is and is not covered, it’s helpful to look into the specifics in more depth with your insurance company to eliminate surprises that can come up along the way when it comes to cost and coverage. We hope this helps you feel more informed when considering expenses associated with building your family.
- Does my health insurance plan cover any fertility treatment? If so, what fertility treatments are covered (IUI, IVF)?
- Is there a specific diagnosis or workup that would need to be documented first to make sure that IUI is covered? Does insurance cover diagnostic testing (ie. ultrasound and bloodwork)?
- Are both the medication(s) and procedure(s) covered? Is there a specific pharmacy that the medication needs to be prescribed through to ensure coverage?
- Do you have a list of fertility specialists (reproductive endocrinologists) in-network that you can provide me with as we move forward with IUI/IVF? Do I have to use an in-network clinic? Do I have to use a specific clinic (e.g., Center of Excellence)?
- Is there a cap on my coverage? Is there a dollar amount, expected out of pocket maximum, a cycle amount or a lifetime limit? Do you have to do certain steps to get to the next level of treatment or qualify for treatment (e.g. try naturally for 12 months, 3 IUI before IVF)
Even after you get guidance from your insurance company, it’s never a bad idea to proactively call your fertility clinic to verify coverage and get a better understanding of cost of services. If you don’t have a clinic yet, your Frame Coach can help you with this process.
How can Frame help me with this process
As always, our Frame team is here to help you navigate next steps in your family building journey. We support our members behind the scenes so they feel more prepared to call their insurance carrier directly to better understand their coverage. Our goal is to make this journey easier for you, and we want you to know that our Frame Coaches are always here to answer questions or concerns that you may have.
