The days of simple to understand, one plan fits all health insurance are long gone. Virtually all plans now contain high deductibles, co-insurance, co-pays and non-covered services. It is vital for you, our patient, to understand what all of these terms mean and how they will affect your out of pocket cost for treatment at the Center for Reproductive Health.
In an infertility practice, we are usually dealing with one of three possible scenarios:
1) NO COVERAGE
Your plan may stipulate that neither diagnostic testing NOR treatment for infertility is a covered service. In this scenario, all services provided by our office are direct out of pocket expenses to you. Talk to our insurance department about our cash prices and our cycle fees.
2) COVERAGE FOR DIAGNOSTIC TESTING FOR INFERTILITY ONLY.
This is a relatively common scenario. With this coverage, your insurance company is stating that it will pay for anything that is coded by the doctor as “fertility testing” V26.21. The insurance will NOT pay for any services that the doctor codes with a diagnosis of infertility. There are several codes under the general category of infertility. Again, we have cash prices and cycle fees available for our patients with no treatment coverage.
3) COVERAGE FOR DIAGNOSTIC TESTING AND TREATMENT OF INFERTILITY
Under this scenario, the insurance company will cover most services – TO THE EXTENT OF YOUR POLICY LIMITS- relating to diagnosis AND treatment of infertility. There are some exceptions to even this coverage such as procedures that the insurance company deems “investigational”. A list of these non-covered services is available from our insurance department. Please remember that when we ask your insurer for information regarding your coverage that nothing they tell is guaranteed to be correct. In most instances the information given to us by your insurer is accurate, but there have been a number of cases where information from insurers has been partially or totally incorrect. Ultimately, it is up to you – the insured – to verify your coverage.
PLEASE BE AWARE THAT MOST COVERED SERVICES ARE STILL SUBJECT TO DEDUCTIBLES, CO- INSURANCE AND CO-PAYS, DISCUSSED BELOW.
There are those fortunate few who will have full infertility treatment coverage with no deductible, 100% coverage and no co-pays. But for the vast majority, the issues of deductibles and co-insurance will play a huge role in how you budget your health care spending. Deductibles are out of pocket expenses, the annual amount of which is determined by a contract between your employer and the insurance company. They are NOT determined by our office. We must collect them because it is the law. If we do not collect deductibles, we will not get paid. Your deductible is simply the amount of out of pocket cash you have to pay for services BEFORE your insurance company is required to pay anything. For example, if your deductible is $1000 per year, that means you must pay the first thousand dollars of services each year directly to the provider. Until that $1000 is paid, your policy will not “go into effect” and start to pay on your behalf. Unfortunately, insurance companies are utilizing high deductibles as a way of saving them money. We are seeing many deductibles in the several thousand dollar range per year. It is important to understand that the amount you pay per visit until your deductible is met is equal to the amount your insurance company would have paid had your deductible already been met. To use our example again, if your deductible is $1000 starting January 1 and you incur a service in our office for which your insurance company would have paid $300, then we have to charge you $300. Your deductible now stands at $700. This process continues until your deductible reaches $0, at which point your insurance company will start processing claims based on the limits of your policy. Our office will try to help with information about your deductible but it is ultimately up to you to know the amount of deductible and budget for the out of pocket expenses you may have until it is met.
POLICY LIMITS AND CO-INSURANCE
Although large deductibles tend to inflict the most pain on health insurance consumers, limits of your coverage may also cause significant out of pocket obligations. We often talk about policies that offer 90/10 coverage, or 80/20 coverage or 60/40 coverage and so on with a certain out of pocket limit. What does this really mean? Your “out of pocket” maximum is another way insurance companies have of shifting the debt from them to you. The higher your out of pocket, the more you can expect to pay, and the less your insurance company will be required to pay. Let’s look at our example again.
Let’s say you have a policy with a $1000 deductible, with a $500 out of pocket and 80% coverage. As discussed earlier, you will have to pay the first $1000 annually for any covered service. After that, your insurance will pay 80% of what they consider the “usual and customary fee” for any service that you incur. The rest will be your responsibility until you have reached your out of pocket maximum. Let’s say you have met your deductible for the year and you then have services provided by your doctor for which your insurance company deems the reasonable and customary fee to be $200. This fee is not a random number. It represents the agreed upon contract price between your provider and the insurance company. Based on your 80% contract, they will pay $160 of that $200 charge. You will be responsible for the remaining $40. The $40 is often referred to as co-insurance. You will continue to pay out of pocket 20% of every charge until such time (if ever) that your out of pocket payments have added up to $500, after which your insurance will pay 100% of all charges. In rare cases your deductible MAY be included with your out of pocket. However, the majority of times they are separate. It is important to understand that many patients going through infertility treatment will end up paying their entire deductible and much or all of their out of pocket expenses for the entire year.
Not to be confused with co-insurance, co-pays are a set amount which you are required to pay at each visit once
your deductible has been met, but not before your out of pocket has been met. I think it is obvious that there any number of ways in which insurance companies can shift the cost of medical care from themselves to you. And each year we are seeing higher deductibles and less coverage. And remember, all of these limits of coverage, deductibles and co-pays are part of a contract that either you personally or, more often, your employer, has negotiated with your insurance company. It certainly isn’t our idea. Your insurance company will pay us nothing until your deductible has been met and we are bound by law, except in documented cases of hardship, to collect co-insurance and co-pays.
A non-covered service is a medical procedure that will NOT be covered by your insurance. These procedures are deemed experimental by the insurance company and are excluded from the policy. You may have treatment coverage, yet still have some procedures that are considered “non-covered” by your insurance company. These will be pointed out to you when encountered before the procedure so you will be prepared for the cost.