Understanding and negotiating your infertility insurance benefit

May 3, 2011Carole 6 Comments »

Did you know that insurance companies are required to explicitly list everything that is NOT a covered benefit, but not everything that is covered? That means that if your insurance doesn’t explicitly list infertility benefits as excluded, you may have some benefits. This gem, among others, can be found on a section about understanding infertility coverage located at the Ferring Pharmaceuticals website.

If you have any health insurance benefits, you should at some point receive a written explanation of your benefits. You will need to carefully review this booklet. Because infertility services are varied and have various components of care that fall under diagnosis, lab work, physician fees and pharmaceutical costs, you will find bits of infertility-related coverage scattered throughout the booklet, making understanding your benefit like a scavenger hunt. You may find benefits described as Covered Benefits, Limited Benefits and Excluded Benefits. Benefits may be limited in various ways, often by capping out at a dollar amount or in the case of IVF, limiting the number of IVF cycles or establishing eligibility requirements before IVF can be attempted.

The various limits imposed on coverage are confusing and sometimes smack of social engineering. You usually will find that not all treatment options are equally reimbursed. Some companies will pay for tubal reversals rather than IVF, even if IVF is clearly the best option for your particular diagnosis. For instance, a tubal reversal will do you absolutely no good if your partner’s sperm count requires ICSI and IVF for him to father a child with you. Just because “your problem” is corrected with a reversal, doesn’t mean your fertility is restored with your partner.

When you have an idea what is covered, you’ll want to get written confirmation of your benefit from the insurance company. Don’t rely on verbal confirmation over the phone. It might be wrong and promises  can’t be documented if there’s a dispute. Ferring provides a helpful template for patients to use when writing their insurance company about benefits. You can download the Ferring template here and I have copied the main questions for you here:

1. What infertility benefits do I have under my current insurance coverage?

2. Do I have diagnostic infertility coverage allowing the physician to find the cause of my infertility problem?

3. Do I have infertility treatment coverage allowing the physician to perform procedures that will help me become pregnant such as intrauterine insemination or in vitro fertilization?

4. If yes, is there a treatment limit of any kind (dollars or number of attempts)? If attempts, define an attempt.

5. Do I need a referral to visit Dr. (physician’s name)?

6. If you require a referral, how often will I need to update the referral?

Don’t start treatment until you know what your out-of-pocket expenses will be. Your physician and fertility lab should be able to provide you with a written estimate of what your specific treatment plan will cost.

Some employers are open to considering adding infertility benefits for their employees. Companies negotiate with insurance companies when they come up with a benefit plan for their employees. Large self-insured companies have exceptional latitude in deciding which benefits will be offered in employee plans. Some employees have been able to go to their Human Resources Department and successfully argued for adding infertility coverage as a covered benefit for employees.

There are many studies that show that infertility coverage is not the huge financial burden to insurance companies or employees that it is widely assumed to be. The experience at Southwest Airlines was published in Fertility and Sterility Volume 92, Issue 6 , Pages 2103-2105, December 2009, “An employer’s experience with infertility coverage: a case study” demonstrating that a well-designed benefit program can offer high quality cost-effective infertility benefits to employees. Companies assume that infertility coverage is too expensive. The true expense of offering this benefit is often smaller than anticipated for several reasons. First, only a very small percentage of  employees avail themselves of infertility benefits, because employees are older or don’t need it. Secondly, if correctly designed, this benefit may actually be cost-effective in terms of attracting and retaining good employees.

Companies can limit their exposure to claims and expense by limiting the number of IVF attempts or the dollar amounts of coverage. Even with limitations, some coverage is better than no coverage.  Sometimes diagnosis is generously covered, while treatments are severely limited or don’t permit the use of IVF, the most effective treatment option. It probably makes more sense to allocate more of that benefit to coverage of treatments, not diagnosis, especially if IVF can then be offered.

A common misconception is that IVF must necessarily increase insurance costs due to neonatal intensive care unit (NICU) costs associated with multiple and premature births. Ironically, it is precisely the lack of insurance coverage which pushes patients to transfer more and more embryos, to increase their chance of pregnancy in a single self-pay attempt  instead of having more insurance covered sequential single embryo transfers. A well-designed benefit will steer patients toward treatment plans result in healthy singleton births, not multiple gestation pregnancies that are more likely to have medical complications and poor outcomes.

The first step to paying for infertility diagnosis and treatment should be investigating what insurance coverage you might actually have, buried in that benefits statement, verifying those benefits in writing and possibly raising the issue of adding or increasing infertility benefits with your employer.


© 2011, Carole. All rights reserved.

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