Insurance Coverage for IVF

May 14, 2010Carole No Comments »

In spite of research findings that dealing with infertility can be as emotionally difficult as dealing with cancer, most insurance companies do not cover infertility treatments and often view fertility procedures in the same category as medically unnecessary cosmetic enhancements like liposuction, face lifts etc. Only 15 states mandate that insurance companies in their state offer infertility insurance benefits. As of this writing the list of states mandating insurance coverage for infertility included: Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia. The infertility support group Resolve’s website at www.resolve.org has a section devoted to IVF insurance which is very useful. You can look up state-specific information on mandated infertility coverage offered by each of these states.

Whether you live in a mandated insurance state or not,  insist that your insurance company document for you in writing in advance what they will cover and how much you will have to pay in the form of a deductible or co-insurance. You will be amazed at the cost-shifting tricks insurance companies have. Don’t assume that just because you have infertility coverage, it means you won’t have any out-of-pocket expenses. Some insurance policies may pay only for the technical procedures and not for hormonal medications. Other policies may not offer fertility coverage per se, but will allow you to use your drug coverage on stimulation drugs that for an in vitro cycle, are typically 30% of the cost. Even for a relatively inexpensive  stimulation cycle with insemination, since the technical component is small, drug costs may easily represent half of your costs. Also, policies from the same insurance provider can be drastically different under different employers. Just because your neighbor has great IVF coverage from Mama Blue at Best Employer Ever, Inc, your own card from your employer, Just the Basics Inc, can be much less because your employer opted out of the infertility coverage option (unless your state mandated coverage).

Mandated coverage has state-specific loopholes. States have restricted coverage in some instances to exclude certain patient groups, like gay couples, single women or older women. Also if your employer is a small company with few employees, they are usually exempt from insurance mandates.

If you don’t live in a mandated state and can’t move to Hawaii, don’t despair- at least about the insurance options. Even though companies in most states aren’t required to offer infertility coverage, they still might, especially if they consider themselves a top employer and want to attract the best employees.

If you work in a hospital, particularly if it is part of a large health care system that has an ART program within its services, you might find that you have great coverage but only if you go to the ART program within your system. Sometimes using the employee-referred program is a great option, but only if the program is good enough. If the CDC reported outcomes are less than average, you need to make some cost-benefit calculations. How soon will these inexpensive cycles no longer be worth it in terms of frustration and the expenses I do have if I don’t get pregnant right away?  I have been very disappointed in the failure of some large hospital systems to really look at quality issues. Just because they can offer something cheaply, it should still be a better than average service, otherwise they are driving their employees to poor quality services. These same large systems tend to have well-funded advertising campaign crowing about their medical excellence. IMHO, it would be money better spent improving their programs but that’s another post. In any case, because you have read my earlier post “Using CDC reports to find a good fertility doctor…part two”, you won’t be fooled by glitzy marketing.

ASRM has a helpful document describing procedures and insurance codes for reproductive medicine. For 2010, two new codes have been added. One is related to ovarian tissue cryopreservation which is not relevant for most IVF patients. The second is a miscellaneous reproductive medicine code  and description:  “89398, Unlisted reproductive medicine laboratory procedure”. It is unclear what procedures would fall under this code but miscellaneous codes often are not covered.

When you communicate with your insurance provider , you must ask about coverage for these specific procedure codes to ensure that you and your insurance company are on the same page. Your doctor should be able to give you a list of codes for your case once he knows what your treatment plan will be because these are the same codes he will use to get the insurance company to pay him. So if you inquire about the same specific procedure codes, it should be clear to the insurance company which lab procedures will be performed for you. You’ll also have to ask about codes that describe non-lab procedures for various appointments (physician and nurse consults) and special non-lab procedures like ultrasounds and blood work.

To avoid being blindsided by astronomical medical bills, please ask for financial estimates in writing in advance from your doctor and your insurance company, before you start any medical procedure.

© 2010 – 2015, Carole. All rights reserved.

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