Understanding Your Health Insurance Plan

LFM_understanding_insuranceBy: David Jaramillo
Lane Fertility Institute Financial Specialist

When accessing coverage under your insurance Plan, at the beginning of a new year, understanding the plan terms or descriptions of provisions and coverage can be difficult. Below is a list of common health insurance coverage terms to help everyone understand more about their individual Plan:

Deductible: The deductible refers to the amount of money that the insured individual will need to pay annually before any benefits from the health insurance policy can be used. This is usually a yearly amount so when the policy starts again such as 01/01/15, the deductible would be in effect again and would therefore have to be met. Some services such as a physician visit may be allowed under the copay only. However, as the insured individual, you should contact your Plan to understand whether the visit is applied to the deductible or is only subject to your copayment, if applicable.

Co-pay: The co-payment is a fixed amount that the insured is required to pay at the time service is rendered. It is usually required for basic physician visits.

Co-insurance: This is usually a percentage amount that is the insured’s responsibility. A common coinsurance split is 80/20. This means that the insurance company will pay 80% of the procedure and the insured is required to pay the other 20%

Out-of-pocket: This is the cost one would pay out of their own pocket. An out-of-pocket expense can refer to how much the co-payment, co-insurance, or deductible is. Also, when the term “annual out-of-pocket maximum” is used, that is referring to how much the insured would have to pay for the calendar year, excluding policy premiums, if applicable.

Lifetime Maximum: This is the most amount of money the health insurance policy will pay towards certain services (i.e. Infertility treatment not to exceed $2,000.00 per lifetime to include or exclude medications).

Exclusions: The exclusions are the things/services that the insurance policy will not cover.

Coordination of Benefits: If the insured has available two or more Plans that provide coverage for certain conditions, both plans are then billed and will coordinate payment between the primary and secondary Plan but will never pay above the billed amount.

Provider Networks: Most health Plans have health care service providers that have made a deal with the health plan to provide services at discounted rates. Together, these health care service providers are known as the health plan’s Provider Networks. It is important to understand whether your Health Care Provider is considered In-network or Out-of-Network. Even if you have benefits Out-of-Network, in all likelihood, you will have a higher co-insurance due by you along with a higher deductible and any payment made on services that doesn’t pay the charge in full is then your responsibility. For example, if your PPO plan requires a $45.00 copayment to see an in-network specialty physician, but 50% coinsurance if you see an out-of-network specialist, instead of paying only $45.00 to see an in-network specialist, you could end up paying $200-$300 to see an out-of-network specialist, depending on the amount of the bill. HMO plans and some EPO plans will not allow you to use an Out of Network provider.

Prior Authorization: Most health plans won’t allow you to get whatever health care services you wish, whenever or where ever you wish. Since your health plan is paying for at least part of the bill, it will want to make sure you actually need the health care you’re receiving and that you’re getting it in a reasonably economic manner. One mechanism used is a pre-authorization and HMO plans all require this. Some other plans as well (i.e. PPO, POS, EPO) require review/authorization for Specialist services (i.e. Infertility services). Authorization if required must then be obtained before the service is rendered or it will be denied and you could be then liable for the cost.

These are just some of the basic tenets of understanding your Plan coverage. As a patient in a fertility practice, it is particularly helpful to understand these terms to maximize your coverage and minimize unexpected costs.

Please visit Lane Fertility Institute for a list of Accepted Insurance Plans



David Jaramillo. Financial Specialist for Lane Fertility Institute.  Mr. Jaramillo brings over 30 years of experience working in health care finance.  He spent a decade as the financial specialist at the UCSF Center for Reproductive Health where he pioneered novel systems that are still used today to assist patients in navigating the complexities of their fertility benefits.

Let’s Get Started

By: Danielle E. Lane, M.D.

LFM_Lets_Get_StartedThe need for women to understand their reproductive options this New Year is as urgent as ever. In 2012, the Centers for Disease Control (CDC) announced that the only group to demonstrate a rise in first birth rates was women aged 40-44. Birth rates for this group/cohort have increased four-fold since 1985. Consequently, the need for increasing fertility services, mainly due to age, is at an all time high. However, while technology has provided some treatment and prevention strategies, cost remains a significant barrier to access.

Mercer, a leading benefits consultant company conducted its annual survey of employer health benefits. Survey results for 2014 indicated that nearly one third of companies with 500 or more workers do not provide coverage for infertility services. The Bay Area is unique in that high-tech companies are more likely to cover fertility benefits. Mercer found that 45% of high-tech companies cover in vitro fertilization and 27% cover other advanced reproductive procedures such as egg freezing. This is compared to non-high-tech companies with comparable figures of 26% and 14%, respectively.

In 2014, Facebook began to offer up to $20,000 in egg freezing coverage for medical or non-medical reasons for its U.S. based employees, and in 2015, Apple followed suit offering their own egg freezing benefit. And while Silicon Valley is likely providing this benefit to attract recruits in an increasingly competitive market, it still remains a critical need for women and a paradigm shift in employer health benefits.

Sadly, while companies offer the benefit, many fertility clinics refuse to contract with insurance companies. Further, many couples may be unfamiliar with the financial impact of paying cash up front and then attempting to submit their own claims, a path that may cost them thousands of dollars out of pocket.

Alternatively, some companies may offer the fertility benefit, but make access so difficult that the benefit frequently goes unused. For example, women are commonly required to undergo three to six months of subpar treatment before gaining access to more successful in vitro fertilization procedures (a concept the policies refer to as “lesser before greater”). Other companies’ policies refuse to cover single women or same-sex couples, stating that they have not attempted natural conception on their own for six to twelve months prior to requesting access to their benefit.

In the end, it will be the demands of women that drive continuous change in fertility care. Women will demand that companies not only provide benefits, but also make them easily accessible. And women will demand that fertility clinics allow them to use their benefits by choosing not to work with non-contracted providers.

Danielle E Lane, MD, Reproductive Endocrinology and Infertility specialist. Dr. Lane attended McGill University before completing her medical training at the University of Pittsburgh school of medicine, her residency at Yale-New Haven Hospital and her fellowship at the University of California, San Francisco. She opened the Center for Reproductive Health at Kaiser Permanente in Napa-Sola-no in 2005. In 2009 she founded Lane Fertility Institute. The Institute has grown to a four physician, multi location practice with a state of the art embryology laboratory. She is committed to providing education for women about preservation of their fertility and developing lower cost models to improve access to care.