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Insurance Counseling for Infertility Patients

Insurance Counseling: Predetermination of Infertility Benefits

We recognize how important financial considerations are to our patients. In an effort to provide the highest level of comprehensive care and service, our financial team is available to explain the costs of treatment and the extent of insurance coverage prior to a treatment cycle. They are experts in both healthcare and insurance issues, especially those related to infertility.

This expertise allows them to serve as advocates for our patients, knowing who to contact and what questions to ask to uncover infertility benefits. As an added service, we offer a predetermination of benefits program to identify each patient’s insurance coverage for infertility treatment as well as pharmaceutical benefits. We will also file claims with your insurer (HMO only) as well as accept assignment of benefit payments, thereby reducing your out-of-pocket costs. It is important to know that although many plans offer some benefits for insemination services (IUI), very few California insurance plans provide coverage for in vitro fertilization. 

 Reproductive Science Center is contracted with the following insurance plans:

  • United Healthcare policies with United Resources Network benefits (Group plans at Oracle, Cisco, Accenture, Synopsys, Verizon, Williams Sonoma, and RBA Retail Brand Alliance)
  • Hill Physicians Medical Group members
  • John Muir Medical Group members (for patients of Dr. Weckstein, Dr. Willman, and Dr. Hinckley only)
  • Alta Bates/Sutter Medical Group members (for patients of Dr. Willman and Dr. Hinckley only)

NOTE: Benefits vary based on your individual group plan. Participation with one of our contracted plans does not guarantee covered benefits. Contact your insurance plan directly for detailed benefit information.

We know that understanding insurance benefits or obtaining the necessary referrals or authorizations to begin treatment can be very confusing. To minimize any financial anxiety, it is important to have a good handle on the processes that are required by your insurance plan. In order to assist you in this we have provided you with some tools for your insurance investigations.      

Understanding Insurance Coverage for Infertility Treatment [link here]

Understanding Insurance Coverage for Infertility Treatment

Here are some tools that may help to “demystify” your coverage for infertility treatment.

Understanding Insurance Policy Types
There are 3 types of insurance policies: Private Indemnity, PPO, and HMO.

1.  Private Indemnity
   1. Medical services are provided by any physician (choice of patient)
   2. May have a deductible
   3. Insurance reimbursement is usually 80-100%
   4. Patient’s responsibility is 0-20% of the physician’s fee.

2.  PPO – Preferred Provider Organization
   1. Medical services are rendered through a Network of Physicians that are contracted with the insurance company.
   2. Deductible must be met before 80-90% insurance reimbursement of their usual and customary fees.
   3. Patient’s responsibility is 0-20% of the usual and customary fees.

3.  HMO – Health Maintenance Organization
   1. HMO Direct

  •          Medical Services are provided through HMO contracted physicians
  •          Services must be requested by the primary care physician and authorized by the HMO.
  •          Co-pay’s range from $5-20 per service.

   2. HMO through IPA – Individual Practice Association

  •           Medical services are provided through Direct Contracts with Independent Physicians.
  •           Services must be pre-authorized by the IPA.
  •           Co-pays range from $5-20 per service and 50% of contracted fees.

Tools for Maximizing Insurance Benefits:

  • Get to know your plan
  • Get a copy of the contract and/or the summary plan description that includes a listing of included/excluded services.
  • Determine the exclusions for coverage
  • Note that “Infertility services excluded” means that neither diagnostic nor treatment is covered.
  • Infertility covered, but no artificial insemination, nor assisted reproductive technology covered” usually means diagnostic procedures, surgery, or monitoring of drug therapy may be covered.
  • be your own insurance advocate

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Sample "Predetermination of Benefits" Letter [link here]