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HMO (Health Maintenance Organization) plans work through medical groups, such as Brown & Toland, and require you to see only doctors within that group to receive coverage. To qualify for coverage for an initial consultation with an infertility specialist at MFC, your primary care physician or Ob/Gyn must obtain HMO authorization before your visit. Without prior authorization, the visit will not be covered. To ensure fertility insurance coverage, it is not enough for your primary care physician or gynecologist to simply “refer” you to a specialist.

PPO (Preferred Provider Organization) plans allow you to see a fertility specialist either within or outside a network, but out-of-network visits typically involve higher out-of-pocket costs. Most PPO plans do not require prior authorization to see a fertility doctor, and you can often schedule an appointment without a referral. PPO plans usually provide a list of in-network providers, but it is recommended to confirm coverage directly with the insurance company. It is not uncommon for patients to have a 50% co-pay for visits to an infertility specialist, meaning the patient pays half of the cost while the insurance plan covers the other half.

Kaiser is an HMO plan and only covers services provided within the Kaiser Permanente system. There is no coverage for outside fertility specialists such as MFC. Whether your Kaiser plan includes infertility evaluation or treatment depends on your employer’s specific benefits. Individual Kaiser policies usually do not include infertility coverage. Some Kaiser plans may include infertility riders that allow IVF treatment outside the Kaiser system.

Your employer—not the insurance company—determines what fertility benefits and IVF cost coverage are included in your plan.It is a common misconception that insurance companies define coverage. In reality, different employers may offer different fertility treatment benefits, even when using the same insurance provider. For example, one employer’s Aetna plan may include IVF coverage, while another employer’s plan may exclude it due to lower premium levels.

As a fertility patient, it is important to carefully review the details of your insurance plan, including benefits and exclusions. If your plan documentation is unclear, you should contact your Human Resources department and/or your insurance provider directly to verify the extent of your fertility coverage.

PPO Plans

• Aetna
• Cigna
• Blue Cross
• Health Net
• Blue Shield
• United Health

HMO Plans

• Brown & Toland
• Sutter of the Redwood
• Meritage

Nearly all treatments will require authorization and insurance companies can take up to 14 days to determine if a service is medically necessary 

Nearly all fertility treatments, including IVF and IUI, require prior authorization. Insurance companies can take up to 14 days to determine whether a service is medically necessary, which may affect the overall timeline of your treatment.

1. Do I have infertility benefits?
2. Do I have a diagnosis to find out the cause of my infertility?
3. Do I have infertility treatment coverage (IUI, IVF, and injectable medications)?
4. Does my fertility coverage include embryo or sperm freezing, ICSI, donor egg, or donor sperm?
5. Does my policy require prior authorization for these procedures?
6. Do I have a maximum dollar amount or a limit on the number of treatment cycles?
7. Do I need a referral or authorization to see a fertility specialist?
8. Do I have out-of-network coverage?
9. What is my co-pay?
10. Always get the name and a reference number for the call.

It is common for fertility insurance plans to provide coverage for diagnostic testing used to determine the causes of infertility, but offer little or no coverage for fertility treatment, especially IVF. Diagnosis may include consultations, blood tests, semen analysis, ultrasounds, and hysterosalpingogram (HSG). Donor eggs, donor sperm, and surrogacy are usually excluded from fertility insurance coverage.

Insurance companies have established guidelines for infertility treatment, including pre-treatment notification, age limits, and requirements to complete simpler treatments before progressing to more advanced therapies such as IVF.