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HMO (Health Maintenance Organization) plans work through medical groups, such as Brown & Toland, and you must see only doctors within this group to receive coverage. In order 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 coverage it is not enough for your primary care physician or gynecologist to just “refer” you to a specialist.

PPO (Preferred Provider Organization) plans allow you to see a specialist within a network or outside a network, but your cost or co-pay for going outside the network is higher. Most PPOs do not require a prior authorization from a primary care physician to see a specialist and you can make an appointment without a referral. The PPO plan should provide you with a list of doctors within their network, but it is best to confirm it by a direct phone call to the insurance company. It is not uncommon to have 50% copay for visits to an infertility specialist which means that you pay half of the cost, and the insurance plan pays the other half.

Kaiser is an HMO plan, and it only covers services by physicians in the Kaiser Permanente group. There is no coverage for outside specialists such as MFC. Whether or not your Kaiser plan covers infertility evaluation and treatment with a Kaiser physician depends on which plan your employer has purchased. Individual Kaiser Policies usually do not include infertility coverage. A few Kaiser Plans include infertility riders which allow subscribers to undergo IVF outside the Kaiser system.

Your employer, not the insurance company, decides what is covered. It is a common misconception that employee benefits are determined by the insurance company. Different employers have different benefits packages with the same insurance company. For example, Aetna may cover IVF for one employer who pays higher premiums and but not cover IVF for another employer whose premiums are lower.

As an infertility patient you need to investigate the extent of your coverage within each plan. Your employee package should include a brochure about your benefits and exclusions from coverage. If the brochure is not clear, you should to call the Human Resources department and/or the health insurance company to verify the extent of 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

The provider is participating with your insurance and has a contracted rate. Our IVF Lab does not participate in any HMO or PPO plans. All Lab services, such as IUI preps, semen analyses and embryology services are available on a self- pay basis and must be paid for at the time of service. A super bill is provided if you choose to submit these charges to your insurance company

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)
4. Does my infertility coverage include freezing of embryo or sperm, ICSI, Donor
   egg or sperm?
5. Does my policy require prior authorization for these procedures?
6. Do I have a maximum dollar amount or a number of try?
7. Do I need a referral or authorizations to see a 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 insurance plans to provide coverage for tests to determine the reasons for infertility but provide little or no coverage for 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 coverage.

Insurance companies have instituted several guidelines regarding infertility treatments including pre-treatment notification, age limits or completion of simpler treatments before more complex therapies.