Navigating the world of fertility treatments is challenging enough without the added stress of understanding insurance coverage. By taking a strategic approach, you can maximize your current benefits, utilize available funds, and prepare for treatment with confidence.
Common Insurance Codes
Understanding Your Insurance Policy & Fertility Coverage
Understanding your insurance policy can feel like deciphering a complex puzzle, but it’s a crucial step toward making the most of your fertility coverage. Start by gathering all your insurance documents, including your plan description and any policy amendments that add coverage for fertility treatments. Next, look for specific insurance caps or coverage limits. Take note of any exclusions or conditions that might affect your eligibility for coverage, for example, do you need to try to conceive naturally for a year or try IUI first before IVF treatments will be covered by insurance? Understand any in-network vs out-of-network differences in coverage and costs.
Additionally, don’t hesitate to reach out to your insurance company for clarification. Speaking directly with a representative can help clarify the language used in your policy and provide insights into benefits that might not be immediately obvious. Ask questions about pre-authorization requirements, necessary medical documentation, and any co-pays or out-of-pocket expenses you should anticipate.
Insurance Coverage for Fertility Treatments in Illinois
Illinois is a mandated state which means that Illinois law requires insurance companies to provide coverage for diagnostic tests and treatment to those receiving insurance from an employer with more than 25 employees. However, there are exceptions. The law does not apply to individual policies, small group policies (fewer than 25 employees) or insurance policies outside of Illinois (i.e., it may not be covered if you live in Illinois but have insurance through an employer in another state).
Even if your employer does not meet this criteria, it’s possible you may still have fertility benefits. Coverage for fertility diagnostics and treatment can vary significantly depending on your insurance provider, employer plan, and state of residence. Review the plans we accept on our Insurance & Financing page to get a sense of where your coverage starts.
What Insurance Covers
While each insurance plan differs, many offer coverage for a range of fertility-related services. These typically include:
- Doctor Consult: Almost all patients who have an in-network plan with Fertility Centers of Illinois have an insurance plan that covers the initial doctor consultation where you will discuss your goals, fertility testing, and treatment plan.
- Fertility Testing: Many insurance plans cover diagnostic tests to understand the cause of infertility.
- Fertility Treatments: About 70% of insurance plans offer some fertility testing and treatment coverage for procedures like intrauterine insemination and in vitro fertilization (IVF).
- Additional Benefits: Beyond the basics, it’s worth investigating if your insurance plan offers additional benefits like fertility medications, preimplantation genetic testing (PGT), using a donor or surrogate, or cryopreservation of eggs, sperm and embryos.
After your initial consultation with Fertility Centers of Illinois physician, you will be assigned a financial educator who will walk you through what your plan does and does not cover. We also recommend reaching out to your insurance provider directly to get a clear understanding of what is covered in your specific insurance plan.
Additional Financing Options
When insurance, state-mandated coverage, or an employer-sponsored plan doesn’t cover the full cost of care, additional financing options can help close the gap. We offer several programs designed to make treatment more manageable and predictable.
- Payment plans and financing: Manageable financing, offered through CapexMD, provides 0% financing for the first six months of treatment, with loan terms up to 84 months. Grant programs, including the Tinina Q. Cade Foundation, can also help offset costs for qualifying patients.
- Fertility Access refund and multi-cycle discount programs: We partner with Fertility Access to provide bundled IVF cycle discounts and refund programs that can help patients save up to 40% on treatment costs. Some exclusions apply.
- HSA/FSA funds and discount programs: An HSA or FSA typically can’t be used for insurance premiums, but it may cover co-pays, deductibles, lab tests, over-the-counter pregnancy tests, ovulation predictor kits, breast pumps, and prenatal vitamins.
Common Insurance Codes for Fertility Treatments
Familiarizing yourself with common insurance codes can facilitate discussions with your insurance provider and help ensure accurate billing. Here are some frequently used codes:
In vitro fertilization (IVF) procedures:
- 58970: Follicle puncture for oocyte retrieval
- 58974: Intrauterine embryo transfer
- 89250: Culture of oocyte(s)/embryo(s), less than 4 days
- 89254: Oocyte identification from follicular fluid
- 89268: Insemination of oocytes
- 89272: Extended culture of oocyte(s)/embryo(s), 4-7 days
Artificial insemination (AI) and intrauterine insemination (IUI):
- 58322: Artificial insemination; intrauterine (IUI)
- 58323: Sperm washing for artificial insemination
Assisted reproductive technology (ART) procedures:
- 89251: Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture
- 89255: Preparation of embryo for transfer
- 89258: Cryopreservation; embryo
- 89261: Sperm isolation; complex prep (e.g., Percoll gradient, albumin gradient) for insemination or diagnosis
These codes are based on the Current Procedural Terminology (CPT) system and are used for billing and insurance purposes. Discussing these codes with your provider and insurance company can help clarify coverage specifics. This list is regularly updated, and other codes could be billed for your treatment plan. Please speak with your Financial Educator for more information. This list is not a comprehensive list of all codes that may be billed but can serve as a helpful guide.
Maximize Your Insurance Benefits Before Year-End
Knowing your insurance benefits and utilizing them can provide financial relief when going through fertility treatments. Most insurance plans have an annual renewal period, meaning unused benefits don’t roll over. Not using these benefits by December 31st, or whenever your renewal period occurs, is essentially leaving money on the table.
When the end of the year approaches, it’s important to review what you’ve used and what remains, allowing you to plan and act accordingly. Schedule any remaining appointments, tests, or procedures before the end of the year to ensure you’re utilizing this year’s benefits and potentially saving a significant amount of money.
- Insurance Deductible: If you’ve already met your deductible for the year, completing as many treatments as possible before it resets can be financially beneficial. Leveraging your current deductible status can help mitigate the expenses of procedures like IVF or egg retrieval.
- Out-of-Pocket Maximums: If you’re close to reaching your out-of-pocket maximum, additional treatments could be covered at little to no extra cost to you. Review your insurance documents to understand these limits and how much you’ve already spent.
- Flexible Spending Account (FSA) and Health Savings Account (HSA): Fertility treatments and medications typically qualify as eligible expenses for FSA and HSA accounts. Remember, FSAs, in particular, often have a use it or lose it policy by the end of the year, so review your balance and spending options before year-end.
Open Enrollment and Marketplace Insurance Plans
If you’re shopping for a plan during open enrollment, which happens towards the end of the calendar year, it’s important to ask the right questions about fertility care. Here are some questions to consider:
- Does the plan cover fertility testing and treatment?
- Are there limits on the number of cycles covered for treatments like IVF?
- Is there coverage for fertility medications?
- What are the requirements or criteria to qualify for fertility benefits?
Understanding the answers to these questions can guide you in selecting a plan that aligns with your fertility goals and financial considerations.
Take Action Today
As you navigate the intricate world of insurance, remember that you are not alone. Your Fertility Centers of Illinois care team is here to support and guide you every step of the way on your path to parenthood.
Editors Note: This post has been updated for accuracy and comprehensiveness as of September 2026.
