Infertility Treatment
Provider Type
- Physicians
- Ancillary
- Participating Physician Groups (PPG)
Some plans cover specific infertility services as referenced in the member's Evidence of Coverage (EOC) or Certificate of Insurance (COI). Before beginning infertility treatment, the member's treating practitioner must establish a treatment plan. Refer to the Schedule of Benefits for specific information concerning plans that cover gamete intrafallopian transfer (GIFT). If these benefits have not been purchased, Health Net must notify the member in writing of coverage limitations.
If a member has not conceived in a particular treatment plan, the member's treating practitioner should re-evaluate the plan and change the therapy. If the member is still unsuccessful, advanced treatment under the guidance of a reproduction endocrinologist or fertility specialist should be considered. The treatments below are covered when the following specified conditions are met:
- Artificial insemination (AI), intrauterine insemination (IUI), GIFT and sperm washing - Covered when used in treatment of infertility (ovulation sticks are not covered)
- IVF/ZIFT - Only certain plans cover IVF or ZIFT. Refer to the Schedule of Benefits for specific plan information
Refer to the Schedule of Benefits (SOB) for availability of infertility treatment; this is also referenced within the member's Evidence of Coverage. The treatment used for each infertile member may be different and should be individualized based on medical indications. Most Health Net plans subject infertility services to a 50 percent copayment. The copayment amount is based on the percent copayment multiplied by the average wholesale price or the actual cost of the injected substance, whichever is less.
The required copayments for infertility procedures may or may not apply to the out-of-pocket maximum (OOPM). Refer to the Introduction pages of the Schedule of Benefits for a list of exception groups.
GIFT is covered when:
- Plan covers standard infertility treatments/benefits
- GIFT procedure is medically indicated
- GIFT is performed by a reproductive endocrinologist or fertility specialist
Infertility Treatment (Ancillary and PPGs only)
Diagnosis of infertility may be appropriate for members who have not yet gone through menopause and have any of the following:
- The member has had coitus relations on a recurring basis for one year or more without use of contraception or other birth control methods which has not resulted in a pregnancy, or when a pregnancy did occur, a live birth was not achieved.
- The member does not have coitus with a male partner.
- A licensed physician's determination of infertility, based on the member's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors.
Infertility services is an optional benefit in employer group plans. When Health Net plans cover infertility treatment, coverage includes procedures consistent with established medical practices in the treatment of infertility by licensed physicians and surgeons including but not limited to diagnosis, diagnostic tests, medication, surgery, artificial insemination (AI), intrauterine insemination (IUI) and gamete intrafallopian transfer (GIFT). Some custom employer group plans include coverage of advanced reproductive technologies (ART), in vitro fertilization (IVF) and zygote intrafallopian transfer (ZIFT). Refer to the Schedule of Benefits and Evidence of Coverage (EOC) or Certificate of Insurance (COI) for coverage information and applicable copayments. Before beginning infertility treatment, the member's treating provider must establish a treatment plan.
If a member has not conceived in a particular treatment plan, the member's treating provider should re-evaluate the plan and change the therapy. If the member is still unsuccessful, advanced treatment under the guidance of a reproductive endocrinologist or fertility specialist should be considered. The number of cycles, or a dollar amount limit of a particular treatment plan and assistive reproductive technologies, may be limited under the member's plan. Consult the member's evidence of coverage. The standard and advanced treatments below are covered when the specified conditions are met.
Standard Infertility Treatments
Intrauterine insemination may be performed using either the partner's sperm or donor sperm.
Donation, storage and banking of member or donor sperm are not covered.
GIFT is covered when:
- Plan covers standard infertility treatments/benefits
- GIFT procedure is medically indicated
- GIFT is performed by a reproductive endocrinologist or fertility specialist licensed in the field
The required copayment for infertility procedures may or may not apply to the out-of-pocket maximum (OOPM), Refer to the introduction of the Schedule of Benefits for a list of exception groups.
Advanced Infertility Treatments
Assisted reproductive technologies (ART), IVF and ZIFT are advanced infertility treatment procedures.
For plans that cover ART, but limit the services to dollar limits, or a specified number of cycles per lifetime, ART is defined as:
- All office visits, procedures, blood work, and ultrasounds performed in preparation for oocyte retrieval
- Retrieval of the oocyte itself
- Culture and fertilization of the oocyte
- Embryo transfer
A cycle is counted toward the lifetime maximum once the member has had her oocytes retrieved, whether or not there is fertilization of the oocyte.
Before a member is eligible for ART coverage, alternate treatments must be attempted without success. The treatment used for each infertile member may be different and should be individualized based on medical indications. Most Health Net plans subject infertility services to a 50 percent copayment. The copayment amount is based on the percent copayment multiplied by the average wholesale price or the actual cost of the injected substance, whichever is less.
The required copayments for infertility procedures may or may not apply to the out-of-pocket maximum (OOPM). Refer to the Introduction of the Schedule of Benefits for a list of exception groups.
Exclusions and Limitations
General infertility services that are not covered include:
- Ovulation kits
- Partner's diagnosis and treatment if the partner is not covered by Health Net
- Benefits for reversal of voluntary sterilization unless otherwise stated by the member's EOC or COI
- Infertility treatment needed as a result of prior voluntary sterilization
- Donation, storage and banking of member or donor sperm or ova for future use
- Unless otherwise stated in the EOC or COI, the testing, storage and transport fees or any other charges incurred
- Sperm washing when used in preparation for a non-covered procedure
- Surrogacy or gestational carriers unless the surrogate is a Health Net member who has been diagnosed with infertility. When compensation is obtained for the surrogacy, Health Net or the participating provider may have a lien on such compensation to recover its medical expense
- Gender selection
- Donor eggs for women with genetic oocyte defects
- Donor sperm for men with genetic sperm defects
- Genetic engineering
- Co-culture of embryos