Does blue cross blue shield of texas cover infertility

Fertility insurance & managed care options in our Austin Fertility Clinic

In order to accommodate the needs and requests of our patients, Texas Fertility Center’s Austin Fertility Clinics are enrolled in several managed care health plans.  We will be happy to file all claims for covered services rendered if we are contracted with your insurance carrier.   In the event that we are not contracted providers, we will supply a detailed receipt of services to you that you can submit directly to your insurance carrier for reimbursement.

Insurance coverage for infertility can often be confusing.  Many policies offer coverage for testing to determine the cause of infertility — but no coverage for fertility treatment.  Usually, your first visit and first sonogram are considered to be diagnostic services and are therefore covered by those policies that cover diagnostic services.      Knowing what your policy covers before seeing your physician or beginning treatment can be very beneficial.  An Insurance Benefit Questionnaire , along with sample letters of predetermination, are available on our website to aid our patients in determining what is covered by their insurance plan.

Our Austin Fertility Clinic billing staff is available to answer any questions patients may have regarding their insurance benefits, insurance coverage and pricing.   The Billing Staff can be reached at (512) 451-0149 option #8..

Contracted fertility insurance plans in our Austin Fertility Clinic

At this time, our Austin Fertility Clinics are contracted with the following plans

• Aetna:  Patients must register with the “Aetna Infertility Program” by calling (800) 575-5999 prior to the initial appointment.
• ARIA (Austin Regional Independent Associates Network)
• Blue Cross Blue Shield (NOT Blue Choice Solutions, Traditional, Indemnity, or Advantage)
• Galaxy (excluding discount programs)
• Healthsmart
• Progyny
• Seton Health Plans
• United Healthcare

All HMO plans and some other specific plans (i.e. Healthselect) require a referral from a Primary Care Physician before a patient can be seen at Texas Fertility Center.  We strongly encourage patients to check with their insurance company to confirm whether or not a referral is required.    Also, Texas Fertility Center does not participate in any government-sponsored health plans such as Medicare, Medicaid, MAP, or Tricare.

Due to the changes with insurance participation in the Affordable Healthcare Act, as of January 1, 2017, TFC will not be contracted with any Marketplace health plans.

Estimating the cost of In Vitro Fertilization (IVF) in Texas involves benchmarking what you must spend without insurance against what your healthcare plan might pay in claims.

Baseline spending runs the gamut because of the many optional services that affect success rates. For example, paying extra for fertility medications can avoid an expensive additional cycle after a failed attempt.

Although the Lone Star State has an insurance mandate, not every couple will have a plan that covers IVF treatment, given their medical history and situation, at any clinic they choose.

Cost of IVF Texas without Insurance

Many Texas couples must fund the entire cost of In Vitro Fertilization without insurance. However, quoting a reliable average figure is misleading because of the many optional services you could choose, and their impact on success rates.

• Base cycle: $12,000
• Fertility medications: varies by dose and prescription
• Donor eggs: $17,000
• Donor sperm: $2,000
• Intracytoplasmic Sperm Injection: $2,000
• Gender selection: up to $5,000

Paying extra for some of these optional services can boost success rates from 25% to 75%. Tripling your chances of needing only one cycle makes a huge difference in the affordability of bringing home a baby – your goal.

Financing

Start a personal loan request to obtain the funding needed to pay for IVF without help from your health insurance plan. If approved, a lender licensed in Texas will deposit money directly into your checking account.

Add the financing charges to your total estimated expenditure, which vary based on your credit qualifications.

• Origination fees up to 6%
• Annual interest rates up to 36%

Use the borrowed money to shop around for the fertility clinic with the best success rates for couples with your specific medical condition. After all, spending money on one cycle is much cheaper than paying for two, or three, or more.

Grants

Finding grants can make IVF costs more affordable for Texas couples without insurance – if you can find one and met the qualifications. Grants are very popular because it is free money that you do not have to repay. However, the free component makes them extremely scarce.

• The federal government does not provide grants directly to individuals. Instead, the government funnels resources to universities, state agencies, and non-profit organizations. Follow the money trail at the grants.gov website.
• Charitable foundations organized as 501(c)(3) nonprofits often promote grants to low-income couples struggling with fertility issues. However, these foundations rely on the generosity of donors, which limits the number of families they can help, and the level of support they can provide.
  • Fertility Foundation of Texas
  • Sparkles of Life

Effortless

Effortless IVF, based in the Dallas Ft Worth area, offers a low-cost, simplified method for patients without insurance. The clinic places the eggs and sperm together in an “INVOcell,” which they then insert into the woman’s vagina. The process reduces the amount of expensive lab work, doctor visits, personnel, and medications needed.[1]

The Effortless IVF website touts similar success rates at half the price. However, make sure to factor in mileage and hotel expenses if you have to travel from Houston, San Antonio, Austin, El Paso, and other distant cities.

Cost of IVF Texas with Insurance

The cost of In Vitro Fertilization in Texas with insurance is where tiny details have enormous consequences. Therefore, quoting an average figure would be very misleading because of the many variables that affect what couples must spend out-of-pocket to bring home a baby.

First, two types of supplemental coverage address expenses associated with the successful outcome of IVF – but only if you purchase these policies before completing a cycle and becoming pregnant.

• Short-term disability replaces a portion of mom’s income during the time she is unable to work for three common scenarios.
  • Pregnancy complications requiring bed rest before childbirth
  • Recovery from labor and delivery
  • Postpartum medical issues that delay return to work
• Hospital indemnity makes claim payments for two common scenarios.
  • Mom’s hospital confinement for childbirth
  • Neonatal intensive care unit (NICU) stay
    • Seriously ill baby
    • Twins or triplets born prematurely

Second, primary healthcare plans cover specific treatments when subject to the state mandate, but still leaves couples with unreimbursed expenses.

• Deductible
• Copayments
• Coinsurance
• Balance billing from out-of-network clinics

Mandate

The Texas IVF mandate creates a wide range of treatment cost outcomes because of the many criteria that a couple must fit to have coverage. The law has eligibility rules for the plan type, and patients.

Plan Types

The cost of IVF in Texas is lower with insurance only if your plan type fits the mandate definition, exclusions do not apply, the employer chooses to offer the option, and the employee enrolls in the plan with the exclusive benefit.

First, the mandate applies only to specific plans.[2]

Second, the mandate excludes specific types of insurers and contracts from the requirement.

• Bonafide religious denomination acting as an insurer, health maintenance organization, or self-insuring employer
• Policy or contract of insurance with a state agency, department, or board

Third, the law requires subject companies to offer at least one plan covering IVF for the group and association market. Employers and unions then decide whether to make the option available to employees and members.

Fourth, employees and members must opt to enroll in the plan covering IVF, which likely has a higher premium than the alternative without the benefit.

Patient Qualifiers

The cost of IVF in Texas is cheaper with insurance only if the patient meets the mandate qualifiers. Only couples whose personal circumstances fit the criteria will spend less money out of their own pockets. [3]

• History of infertility of at least five continuous years, or have a specified medical condition
  • Endometriosis
  • Diethylstilbestrol DES exposure
  • Blockage of or surgical removal of one or both fallopian tubes
  • Oligospermia
• Unable to attain a pregnancy through less costly treatment
• The fertilization or attempted fertilization of the patient’s oocytes is made only with the sperm of the patient’s spouse – excludes gay, lesbian, and heterosexual couples using donor eggs, donor sperm, or surrogates

Clinic Rules

The cost of IVF in Texas is more affordable with insurance only when the couple chooses to seek treatment from specific clinics. The issuing company must honor claims only when procedures are performed at a medical facility that conforms to the minimal standards for programs adopted by the American Society for Reproductive Medicine.

BCBS

The Blue Cross and Blue Shield (BCBS) of Texas infertility coverage illustrates how the IVF insurance mandate works in practice. BCBS offers a variety of plans, that cover patients with different medical histories and needs, who try artificial reproductive technologies at clinics throughout the state.

• BCBS provides plans in the individual, small group, large group, association, and consumer choice markets. It offers at least one program covering IVF in the mandated markets and makes that groups aware that the benefit is available.
  • Some employer and union groups opt to include the more expensive alternative that covers IVF to provide their employees and members the opportunity to enroll – or not.
  • Some employees and members enroll in the plan with higher premiums and better IVF benefits, while others pick a cheaper alternative.
• BCBS honors the claims of patients who chose the IVF benefit option and meet the criteria: five-year history, less costly treatment, patient oocytes and spouse sperm.
• BCBS publishes a list of qualifying clinics named the “Blue Distinction Centers for Fertility Care” to point patients to providers meeting the ASRM standards of care.[4]

[1] Effortless IVF

[2] TX Department of Insurance Mandated Benefits

[3] Insurance Code Chapter 1366

[4] BCBS Distinction Centers

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