Insuring You Get the Most Coverage for Infertility Treatment
Posted on August 7, 2012
One of the most challenging aspects of coping with infertility is the high cost of infertility treatment. This is true regardless of the type of treatment you need. There are currently about 15 states that have some type of mandated insurance coverage for infertility treatment. (Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia). You need to check your individual state to be clear on the laws there outlining what types of treatments are covered and if your employer is included in this mandate. The business office at your fertility clinic may also be able to assist you in maximizing coverage for your specific type of treatment.
The laws in these states outline what employers are required by law to help cover some of the costs of infertility treatment. It may not be easy to go to an employer to find out what your coverage is but if you don't advocate for yourself you may be losing out on insurance benefits that you are entitled to.
Before you take this step identify who in your office has the best information about insurance benefits. It is often the human resources department. Prepare yourself by taking these steps:
1. Do your homework and find out what the laws are in your state about your type of infertility treatment. (Your local RESOLVE chapter can help with this)
2. Collect documentation confirming your diagnosis, what treatments you have had, and the doctor recommended treatment you will need.
3. Make sure your employer is aware of the laws in your state governing treatment.
4. Remember you must be honest about pre-existing conditions and treatment or you risk losing insurance coverage.
Many companies offer periodic open enrollment options for employees to select or change an insurance plan. Deciphering the language in insurance booklets can require an interpreter. There are areas you want to consider regarding any potential insurance coverage for infertility treatment:
1. Ask about monthly costs, deductibles, out of pocket maximum, and percentage of coverage.
2. Find out if the fertility clinic or MD you would use is in your provider network. Insurance will pay more costs if they are.
3. Infertility treatment often involves ultrasounds, surgical procedures, lab visits, and medications. What is your coverage for this?
4. How long do you have to try to get pregnant before being referred for infertility treatment?
5. Does your plan require a second opinion and if so who pays for it?
6. Is there a maximum payment clause on your plan on infertility treatment?
7. What specific types of infertility treatment are included or excluded in the plan?
8. Does your plan cover the cost of "experimental treatment" and how is that defined?
9. Is infertility treatment covered if you are away from home? (Perhaps you are using an out of state donor, would a retrieval or ultrasound be covered?)
The mountain of paperwork you get when you receive medical treatment, especially infertility treatment, with its frequent tests, lab work, ultrasounds, and surgical procedures is very intimidating. Creating an organizational plan at the beginning will help you sort through your bills and help determine what, when and how much you have to pay. Here are some ideas about how to approach it:
1. Match up the bill you receive from your provider with the correct Explanation Of Benefits (EOB) Use the dates of service and provider as reference points. The dollar amounts should match. If they don't follow up with provider and insurance company.
2. The EOB explains what your insurance company will and won't pay for and what you will be expected to pay.
3. Understand what your coverage is for in and out of network providers and make sure your EOB reflects this accurately.
4. Create a file where you keep all your paperwork together and have it filed by dates.
5. When you pay a bill document the amount you paid and when it was paid and keep the EOB and bill together in the file.
6. Do not pay any medical bill until you get the corresponding EOB to confirm you are paying the correct amount.
7. If you do speak with someone at your provider office or insurance company document the time, date, their name, and what they told you in case you need it for future reference.
These steps can save you time, money, and lots of anxiety. I used 3 different insurance companies during my treatment and I ended up with 90% coverage with the 3rd company. By paying attention to my bills I also caught my provider double billing me and my insurance company. Advocating for yourself can be challenging but it ultimately can empower you and you can use these skills in the future. It is one way you can get some control over your infertility experience.
Iris Waichler, MSW, LCSW, has a Master's Degree in Social Work and has been a licensed clinical social worker for over 30 years. She has done workshops, individual, and group counseling with people experiencing infertility. Ms. Waichler is the author of the award winning Riding the Infertility Roller Coaster: A Guide to Educate and Inspire. She currently writes freelance infertility and health related articles.