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Participating or Non-Participating, Is That The Question?

Typically, the first question we are asked by patients is, “Are you participating with my insurance?” Although we participate in most plans, a simple “Yes or No” may mislead many patients. The most important question should be, “Do I have coverage for the treatment of infertility?”, since there are still many patients in New Jersey without insurance coverage for infertility treatment. In these cases it does not matter if the physician is a “non-par” (non-participating provider) or “par” since infertility treatment will be an out-of-pocket expense. If this is your situation, we have several options to help you afford your treatment with us.
We participate in the following plans:

  • Aetna: All plans
  • AmeriHealth
  • Beech street
  • CIGNA: Great West Life
  • HealthNet/Physicians Health Services
  • Horizon Blue Cross Blue Shield of New Jersey
    • NJ Direct
    • Direct Access
    • HMO Blue
    • Blue Card PPO (Blue Shield PPO of NJ and all other states)
    • We are unable to participate with Horizon Advantage EPO plans
  • Oxford
  • Multiplan
  • Private HealthCare Systems
    • CoreSource
    • GE Group Administrators
    • Guardian
  • Solaris HealthCare System (under QualCare)
  • United HealthCare

If you don’t see your insurance provider listed here, please give us a call as we may indeed be participating in your insurance network. If we are not “in-network” providers under your plan, generally we can still participate in your  care as “out-of-network” providers, and will work to minimize any out-of-pocket expenses to you.

The NJ Family Building Act

The NJ Family Building Act, (Click Here for PDF file ) was signed into law in 2001 and implemented throughout NJ in 2002. This law requires many NJ employers who purchase health insurance for their employees to cover infertility evaluation and treatment. However, patients seeking infertility treatment must first meet certain clinical criteria in order to be eligible for the benefits. Here are the requirements:

  • If a patient is less than 35 years of age, she must have a 2 year documented history of infertility.
  • If a patient is 35 years or older, she must have a 1 year documented history of infertility.
  • The infertility must not be a result of a voluntary sterilization procedure, i.e. tubal ligation or vasectomy.
  • The patient must have used all reasonable, less expensive, and medically appropriate means of treatment, which have failed, before moving to a more expensive and medically appropriate treatment (IUI before IVF if both are treatment options).
  • If you (male) are not able to impregnate another person (female).
  • If you (female) are not able to carry a pregnancy to a live birth.
  • If you (female) are less than 46 years of age.
  • If you have not yet completed four egg retrievals per lifetime that were covered or paid for by any insurance plan. Self-pay IVF cycles do not count toward the lifetime maximum of 4 egg retrievals.
  • Cryopreservation & storage of charges are not covered by the mandate.

Not all NJ couples have this benefit. Additionally, many NJ residents are covered by insurance plans originating in either NY or PA. These insurance plans must follow the law in the specific state where they are purchased.
Many NJ residents have self-funded or self-insured plans, e.g., The Carpenter’s Union or the Plumbers Union, etc. Other very large employers, because of their size and the way they provide health insurance for their employees are legally obligated to follow Federal Guidelines outlined in the ERISA Act of 1974. This federal law does not provide any provision for covering the diagnosis or treatment of infertility. Therefore these types of plans do not legally have to provide coverage for infertility treatment, however, many do.
Whether you are covered by a self-funded plan or an employer-purchased insurance plan, our goal at The Center for Advanced Reproductive Medicine & Fertility is to help our patients navigate through the “insurance maze”. Our Patient Advocates will complete an Insurance Verification Investigation by telephone to determine the infertility benefits available under your plan. Our advocates may also request written benefit information from your insurance company to confirm the information we have obtained by phone. This vital information will aid you in your decision-making process since infertility treatment has many clinical and financial facets.

For Patients Without Infertility Benefits

If it has been determined that you are not covered or not eligible for coverage under your current health insurance carrier, you may be eligible for a discounted rate for treatment including superovulation-intrauterine insemination cycles, in vitro fertilization and frozen embryo transfer (FET) cycles. These discounted fees will be discussed in detail with one of our financial counselors during your office visit.
For patients who have no insurance coverage and need IVF as a means to conceive, our Affordable IVF Plan, which is just $6300 for full-stimulation IVF cycle (not including medications or anesthesia), may be just what you need to protect your financial assets.

Financing Options

At the Center for Advanced Reproductive Medicine & Fertility, we have employees who meet with patients individually to discuss the financial aspects of your treatment. These patient advocates will review your course of treatment and your insurance coverage with you so that you know what your options are according to your budget and benefits. You are encouraged to ask questions to make sure you understand your out-of-pocket cost, if any, of your infertility treatment.

For patient convenience, we accept personal checks, cash and all major credit cards, VISA, MasterCard, Discover and American Express. Other patients choose to secure personal loans through their credit unions or banks.

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