In Illinois, infertility is mandated by law for companies who have more than 25 employees. Unfortunately, even though infertility coverage is required, there is not a specific set of services that insurance providers need to include. Understanding your infertility benefits can feel like an overwhelming task. We sat down with Reproductive Medicine Institute’s (RMI) billing manager, Jennifer Toro, to get a better understanding of navigating benefits.

“At RMI, we understand how difficult it can be to get information from your insurance company regarding specific infertility benefits, that’s why we have a team of dedicated staff to help.” Jennifer explained that “prior to each new patient appointment, or any procedures performed, we contact the patient’s insurance company and get a detailed explanation of their benefits. We then call the patient and explain what their benefits are and what is not covered through their plan.”

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Taking a proactive approach in your healthcare is important. Many patients will contact their insurance companies to discuss their coverage but are often left with more questions than answers. “We have patients who call our office to see what information they should be asking their insurance company,” Jennifer said, “I wanted to help alleviate some of their stress and put together a list that can help them to get the answers that they need.”

Jennifer’s list of questions that you can use to get the necessary information from your insurance provider:

  1. Do I have coverage for the initial consultation with the physician? Prior to obtaining all of the relevant medical information for a patient, the initial consultation with a reproductive medicine physician is the most important step. If there is a medical problem such as endometriosis, uterine fibroids or thyroid disease, treatment is generally covered by your medical insurance and infertility coverage is not needed. Men may have low sperm count or low testosterone, which is also covered by your medical insurance.
  2. Do I have coverage for infertility?
    1. In Illinois, infertility coverage is mandated by the state and needs to be included in insurance benefits. Unfortunately, there are loopholes to this rule. Depending on the size of the company, type of company, or where the main corporate office is located you may not have infertility coverage.
  3. Is Reproductive Medicine Institute, or a specific doctors name, in-network?
    1. Insurance companies have contracts with different providers offices. Based on what the contract is, you have in-network and out-of-network benefits. Essentially, in-network benefits will get you the best coverage your plan allows.
  4. Do I need a referral for fertility treatment?
    1. Some insurance plans will require your Obstetrician/Gynecologist or Primary Care Provider to give you a referral to see a specialist, if a referral isn’t given, your insurance company can deny care.
  5. What is my copay?
    1. Some insurance plans will require a co-pay, this payment will apply to your out-of-pocket benefits and is paid prior to a visit or service.
  6. What is my yearly deductible?
    1. Your deductible is a set amount by your insurance company that must be met before your insurance will pay on any claims.
  7. What is my co-insurance?
    1. Your co-insurance is the percentage you will pay vs your insurance provider on claims. Often you will see that your insurance provider will pay 80-90% and leave you with 20-10% of the claim.
  8. What is my max out-of-pocket?
    1. Your deductible, co-insurance, and copays will apply to your max out-of-pocket. Once your max out-of-pocket is met, your insurance company should pay at 100%.
  9. Do I have any limitations or maximums for infertility care? Does this include my medications?
    1. Insurance companies will limit the amount of care you can get for fertility. Sometimes this a monetary value and other times it is a limit of the number of times an individual procedure can be performed. It is important to find out if your medications are included in this or separate, medications can monopolize your benefits.
  10. Do I need prior authorizations for my fertility treatment?
    1. For certain procedures, your insurance plan may require that RMI provides a medical reason for the procedure prior to being performed.
  11. Do I need to use a specialty pharmacy for infertility medications?
    1. You may get better coverage for your medications if you use a specific specialty pharmacy.

If you are struggling to understand your plan benefits, or want to get started with your infertility care, contact RMI today to speak with a member of the team.