Insurance and Infertiltiy - Infertility Message Board

Mindoo · 02-28-2003, 06:19 PM

I've noticed in some of these threads there were references to infertility insurance coverage or lack thereof. So, I decided to start a new thread to talk about "tips" and "suggestions" to deal with the insurance company.

I've been fighting my insurance company from almost the beginning. Early on, they paid for all of my treatment. The only thing they wouldn't pay for was the Clomid/hCG. They told my doctor's office my coverage paid for all diagnosis and treatment except for IVF's and GIFT's. However, about half way through last year, the insurance company stopped paying for everything. They said that my plan did not have infertility coverage. The doctor’s office appealed the rejected claims for me, but we lost the appeal.

Thinking that we did not have infertility coverage, my dh and I decided to save money for 3 IUIs this year in a health care reimbursement fund. The money is put in the account tax-deferred and allows us to pay for our medical expenses pre-tax. It’s about a 25% savings for us. I called my insurance company in January to get a letter saying that I didn’t have infertility coverage, so I could submit my claims to the health care reimbursement account. (Health Care Reinbursement requires an explanation of benefits to process claims.) :round The lady on the phone said, “YOUR COMPANY PAYS FOR ALL INFETILITY EXCEPT IVF”. So, this is twice someone at the insurance company has told my doctor or me that it’s paid for. I now have all of last year’s rejected claims under appeal. I appealed through both my employer and the insurance company.

I have also requested a written pre-determination for my future IUIs. Hopefully, the next one will be in late March or early April. If I pay for the procedures at the time of service, I can get a significant discount at my doctor’s office. I would like to know in advance who’s paying -- me or the insurance. If it’s me, I will pay immediately to get the discount. However, it would still be better if the insurance would pay.

Any advice on winning insurance appeals?

Thanks,
Mindy

vonnie · 03-01-2003, 09:36 AM

I can understand how frustrating it is. My dh and I are self-employeed so we pay for our own insurance. Infertility treatment is not covered. However, if you purchase the same exact ins plan through an employee it IS covered. Stupid huh? I read somewhere that insurance companies have been getting sued for not covering infertility. Yet they will pay for a man to receive implants if he is impotent. Because somehow that is devestating to a man, yet a womans inability to have a baby is not. The interesting thing is that most top executives at insurance companies are? Yeh you guessed MEN!

dknees · 03-01-2003, 10:09 AM

One thing I found while searching for an insurance company is that you have to know what you're looking for when you read their coverage "lists." I have an HMO now that I'm marginally happy with and was looking for a change during our last open season. What I found was insurance companies would say they covered infertility treatments, but NOT IUI, IVF, GIFT, etc. OR prescription meds such as clomid or the injectables. I had to look under prescription coverages to find that last bit, it was hidden. So what exactly do they cover? Beats me. I called a couple of places asking what they DID cover, since it seemed all the stuff I'd need would not be covered. Nobody could answer my questions. I ended up staying with the HMO since it's a flat 80% coverage on all services (except IVF and GIFT) and prescription meds. When you figure in $15 copays for every office visit, ultrasound, blood test, HCG shot and IUI, it really isn't as good as it sounds. I paid $500 out of pocket just in copays and meds. I'm getting billed for the 20% that wasn't covered for the IUI's etc. We're figuring it'll be about $900 for one cycle. I know it's FAR better than what many people are paying, but my goodness! What kind of jobs do these doctors/medical companies think we have that we'd be able to afford all this?????????

Mindoo · 03-01-2003, 01:11 PM

Dknees,

Interesting that you brought up HMOs. I live in Ohio and Ohio Revised Code says that HMOs must pay for infertiltiy coverage. But, the same code does not say anything about other types of insurance coverage. My company lead me to believe that all of the plans it offered payed for tbe same services - just at different levels. Because of this I elected the PPO instead of the HMO. However, next year I won't take the company at "face" value. I will definatley ask which services are paid for by each plan. Maybe my company's HMO does pay for infertiltiy coverage due to state law.

Also, any idea how to get a list of services covered by a plan?. I've been asking for this until I'm blue in the face, and I can't get one. In my last request, I asked for a copy of the contract. I'm not expecting anything, but we'll see......

Vonnie,

I'm going to try some strategy similar to what you suggested in my appeal. My sister also did something similar in an insurance appeal and she won! My sister has just the opposite problem we have. (She can't stop having babies. And I'm glad! I love all my nieces and love spoiling them rotten!) She wanted an IUD, but insurance wouldn't pay for it. She said in her appleal that insurance would pay for a man's vasectomy but not and IUD? I would love to get hold of a coverage list is I can detemine inequalities like you mentioned.

Thanks,
Mindy

[This message has been edited by Mindoo (edited 03-01-2003).]

[This message has been edited by Mindoo (edited 03-01-2003).]

dknees · 03-01-2003, 04:08 PM

I work for the gov't, so every year when we have "open season" to change health plans, we are bombarded with pamphlets and brochures from all the plans we have to choose from. I spent countless hours poring over these stupid things. They are organized sooooo poorly. There's usually an index of things covered, with references to the page where you can find more specific info on that coverage. Of course, when there's not much written under "infertility" you know they don't cover much. A lot of them had websites too that I went on which were more helpful, and I started calling different providers. The bottom line is that a lot of people are down on HMO's, but I get pretty good service, same day appointments, good health care coverage and it costs less than other plans I had to choose from.