In a blog in the not very distant past, I promised you that we would be looking at the finance and insurance pieces of fertility treatment. Or rather, the finance and insurance pieces of infertility, even before you get to fertility treatment.

We all want to know what it’s going to cost. None of us want the unexpected and unpleasant surprises of fertility treatments costs that we had not planned for.

When it comes down to understanding the complex world of insurance and finances, it makes sense to understand what language we are talking. Just like infertility and fertility treatment, the financial aspect has its own language. One that completely befuddled me when I first started.  

Reproductive Medicine Associates of Connecticut (RMACT) wants to help de-mystify this. Let’s start by looking at some common definitions of terms that can be confusing. Learning and understanding these terms will build a solid foundation to get to the next steps. One bit at a time.

It was interesting to me to read these definitions. I thought I knew what they meant but wasn’t actually correct about several of them.

What do you think? Are there terms that you read or hear about that are not on our list? Let us know and I will ask our finance experts and get back to you. ~Lisa Rosenthal

Fertility Financing Basics

HMO (Health Maintenance Organization) – these plans usually only offer in-network benefits and will normally require referrals or authorizations. Authorizations are usually required for all covered services.  If your partner is covered under the same plan, he will need to have referrals and authorizations for services rendered to him as well.  

POS (Point of Service) – these plans usually offer both in and out of network benefits.  Most POS plans do require referrals or authorizations for the maximum benefit and the least payment out of your pocket.  If you chose to come without a referral, you will likely be subject to an out of network deductible and higher coinsurance. Authorizations are usually required for all covered services.  If your partner us covered under the same plan, he will need to have referrals and authorizations for services rendered to him as well.  

PPO (Preferred Provider Organization) – these plans usually do not require referrals or authorizations, but you should check with your insurance company as some do require notification of services/cycles.  If your plan covers IVF, you will need a pre-determination letter from your insurance company verifying benefits in order to avoid paying for your cycle up front. 

Referral – an insurance authorization number initiated when a primary care physician or OB/Gyn refers a patient to a fertility specialist.  Obtaining referrals is the patient’s responsibility.  A specialist’s name written on a prescription pad does not constitute a referral.

Authorization – a number issued by an insurance company authorizing a specific service or medication.  Some insurance companies require patients to obtain authorizations and some require the specialist to do so.

Pre-certification – a number issued by an insurance company for a surgery or in-office procedure.

Pre-determination letter – a written verification of benefits for your specific plan from your insurance company.

Copayment – a form of cost sharing in a health insurance plan that requires an insurance to pay a fixed dollar amount for consultations, surgeries, or medical services.

Deductible –the amount you pay in a benefit year before your health insurance begins to make payment towards your claims.

Co-insurance – the percentage of the medical expenses you pay after you meet your deductible.

Out-of-pocket maximum – the maximum dollar amount you pay for covered services; which apply to your copayments and coinsurances.  In some insurance plans, the deductible will also apply to this culmination.

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Topics: Financing Infertility Treatment

Lisa Rosenthal

Lisa has over twenty-five years of experience in the fertility field. After her personal infertility journey, she felt dissatisfied with the lack of comprehensive services available to support her. She was determined to help others undergoing fertility treatment. Lisa has been with RMACT for seven years and serves as Patient Advocate and the Strategic Content Lead.

Lisa is the teacher and founder of Fertile Yoga, a program designed to support men and women on their quest for their families through gentle movement and meditation.

Lisa’s true passion is supporting patients getting into treatment, being able to stay in treatment and staying whole and complete throughout the process. Lisa is also a Certified Grief Recovery Specialist, which is helpful in her work with fertility patients.

Her experience also includes working with RESOLVE: The National Infertility Association and The American Fertility Association (now Path2Parenthood), where she was Educational Coordinator, Conference Director and Assistant Executive Director.

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