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Insurance coverage for infertility evaluation and treatment is completely random and many times arbitrary. Contrary to popular belief, medical insurance coverage of infertility is not up to the insurance company but the employer. When deciding on insurance benefits for their company, an employer can decide whether or not to offer infertility benefits. By doing so, however, it will increase premiums and as result, most employers will elect not to offer infertility coverage as part of the health benefits. Some of the larger companies, or a smaller company where the owner may have had personal experience with difficulty in conceiving or was close to someone that did and got to "experience" it first hand, tend to go with insurance companies that offer some degree of infertility benefits. These "benefits" range from excellent to almost non-existent. Companies that offer good benefits tend to seek out the larger insurance companies that already have "infertility benefit plans" in place. Many of the smaller insurance companies do not an even have "infertility benefit packages to offer" even if the company wanted to go with them. As a result, insurance coverage for infertility evaluation, medications, and treatment for Intrauterine Insemination (IUI) and In-Vitro Fertilization (IVF) varies greatly.
Although, in almost all cases, difficulty with having a baby is a medical problem, many insurance companies offer little to no reimbursement. This is clearly by a conscious choice on their part and leaves the patient having to pay for much needed services (Read about the Arizona Center for Fertility Studies Stimulus Plan). Some insurance plans will offer no infertility benefits, some pay for all of it and many are somewhere in between. Although, 17 states mandate some type of infertility benefits, unfortunately, the great state of Arizona is not one of them. However, there are plenty of companies in Arizona, where employees do have some, and occasionally, very good benefits.
When a woman is first seen as a new patient, Arizona Center for Fertility Studies will immediately call her insurance company and check for what infertility benefits she may have. This information is very useful and gives a couple "one more piece of the puzzle" in helping them decide on treatment options. If the woman has a percentage of infertility benefits, Arizona Center for Fertility Studies will accept payment and wait for the remaining percentage of monies to be paid; and only ask the woman for the difference up front. As an example, if Arizona Center for Fertility Studies confirms that a woman has 70% coverage for IVF, than she will be only asked to pay the remaining 30% up front at the time of treatment; and Arizona Center for Fertility Studies will wait for the insurance company to pay the remaining amount. If after the insurance company sends payment, if there is a balance, it will be billed to the woman.
We will work with you and your insurance company to get the maximum reimbursement possible and, if needed, work out an arrangement that is fair to both of us. If there is no insurance coverage, then Arizona Center for Fertility Studies will work out a price with you that is fair to both of us; as well as go to bat for you, if surgery is needed, to get the best "cash price" at the surgical facility.
Generally insurance companies with traditional percentage plans, PPOʼs and even HMOʼs, with out of network benefits, offer infertility benefits. When a clinic is "out of network" it does not mean that the insurance company will not pay for the services. All it means is, that by not being "in network" with the plan, the woman will usually have a higher amount of "coinsurance" as compared to if they went to a clinic that was "in network". Arizona Center for Fertility Studies sees many patients that are "out of network" because of our reputation of having high success rates, word of mouth, our genuine and demonstrated commitment to our patients and/or recommendations from friends or referring physicians. Unfortunately, many couples have no insurance benefits for infertility whether they are "innetwork" or go "out of network". Therefore, a couple can freely choose a clinic based on reputation and demonstrated commitment to both excellence and their patients. Even if a woman has "in-network" benefits, Arizona Center for Fertility Studies, although "out of network" will always work with that couple and most times take as payment their in-network benefits. Therefore, no patient will ever have to go somewhere else, "for insurance reasons".
Many insurance plans will generally pay for testing associated with the evaluation of infertility. But thatʼs when it gets fun, because once the diagnosis as to the cause of why the couple cannot get pregnant is determined, many insurance companies will not pay for any treatment options. "At least some benefits are better than none", since the infertility work-up is important in order to establish a diagnosis so appropriate treatment options can be discussed. Some will pay for IUI only, with or without medications, and some will even pay for IVF. Occasionally, a woman will have a lifetime benefit for infertility coverage that can range from $5000 to $25,000. Uncommonly, a woman may even have benefits for up to 3 or 4 attempts at IVF. Arizona Center for Fertility Studies will make sure that a woman will know her exact infertility benefits before starting treatment.
The diagnosis of infertility is always a medical problem. In many countries in the civilized world, infertility is considered to be a medical disease and covered by health insurance or the socialized medical system as any other disease would be. In the United States, a number of years ago, infertility was decided to be looked at by insurance companies more as a social issue (Read about the History of Infertility) rather than a medical issue. Of course, companies could "add infertility benefits" if they wanted to but it would cost them. In the end it is all driven by money. No woman has ever chosen to have difficulty with having a baby and reproductive dysfunction is as much a medical problem as a fractured bone, pneumonia, heart disease or diabetes. Infertility is never the diagnosis, it is the symptom of whatever the underlying diagnosis is. When a person breaks a bone in their right arm, the diagnosis is not "loss of range of motion", it is a fracture of the right distal radius. The good news is, that many times surgical procedures are covered, because they are related to an underlying medical condition.
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