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Understanding Fertility Insurance Coverage
Understanding insurance is a complicated process. Understanding fertility costs, coverage, and benefits is even more involved and may leave patients feeling overwhelmed. We hope by providing information which explains some of the details and variations of infertility insurance we can reduce one aspect of the stress in our patient's life.
An important concept to understand regarding insurance coverage is that the state lived in determines what medical treatments must be covered by any insurance provider. The state decides (mandates) what the minimum benefits are that must be provided by any insurance company operating in that state.
What do "dx" and "trx" mean?
Once a patient has determined that they have some type of fertility coverage, their next challenge is to discover the extent of that coverage. Their plan should indicate whether they have only diagnostic ("dx") benefits or whether benefits for treatment ("trx") are also included. Diagnostic coverage means the testing necessary to determine the reason for the patient's problem. Diagnostic benefits may include consultations, blood tests, semen analyses, ultrasounds, hysterosalpingogram (HSG) and things of that nature. Treatment coverage is for resolving the issue. Treatment coverage can vary widely by plan. One plan may include oral medications only, while another plan may include Intrauterine Insemination (IUI)also referred to as Artificial Insemination (AI) - or In Vitro Fertilization (IVF). It is important to note that some options, such as treatment for sex selection when no fertility issues are present, will not be covered because these treatments would not be considered a "Medical Necessity."
Finally, just because one has coverage does not mean there will be no cost. One's benefits may "cap" at a certain amount. This means that a patient's insurance carrier will pay up to a certain amount toward their services (dx or trx or both), but anything more than the predetermined "cap" amount will be their responsibility. It is also possible for the payment process to be reversed. The patient would have to pay a certain amount first, and only after they have reached a certain limit, do their benefits begin.
If a patient's benefits are provided through an HMO, their co-pay can add to their expenses. Many times with fertility treatment this copay amount is more than the total fee for other physicians. Their copay may be as much as 50%. One should be aware of this amount prior to their appointment.
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