Researching health coverage
Who is covered?
Since laws change all the time, it is important that you check with your state concerning its current regulations on infertility coverage. The current state regulations are outlined below.
States where insurance companies are required by law to provide coverage for infertility diagnosis and treatment include:
- Arkansas
- Connecticut
- Hawaii
- Illinois
- Maryland
- Massachusetts
- Montana
- New Jersey
- New York
- Ohio
- Rhode Island
- West Virginia
States where insurers are only required to offer coverage for infertility diagnosis and treatment (it is up to each employer to purchase a “rider” that covers these benefits) include:
The remaining states do not have laws concerning infertility coverage.
Even if a couple has coverage, the extent of the benefits to which a couple is entitled may still vary from one insurance plan to the next. In addition, if a couple receives benefits from an employer that is self-insured, the state mandates do not apply.
Steps to take
Most health insurance plans cover only medically necessary procedures. Since some insurance plans do not consider infertility treatment medically necessary, you need to advocate for yourself when trying to get coverage for full or partial treatment.
Here are some steps you can take when researching insurance coverage:
- Get a copy of the plan’s contract, not just the plan summary. Read the list of exclusions very carefully. The employer’s personnel department can provide a copy of the contract.
- Find out who to contact about coverage at the insurance company.
- Get a written predetermination of coverage before any procedures.
- Follow-up with the contact person to check on the status of the request. If the policy holder has not received a written response from the insurance company after sending the request a second time, then the request should be sent again to the appropriate contact person via certified mail. Also send a copy to the state insurance commissioner (for contact information look up state government listings in the local telephone book).
- Determine how much the plan will pay. Take into account the deductible, co-payments, maximum payment provisions or payment caps.
- Keep accurate records. Keep copies of all correspondence to and from the insurer. For all telephone conversations, write down the date, time, contact person, phone number and issues discussed.
- Use a phone for convenience, but back up these conversations with letters.
- Don’t take “no” for an answer. If coverage is denied for a particular treatment, ask why. Find out whether various procedures used in the treatment can be covered independently. Also, be persistent about resubmitting coverage requests if you are denied initially.
- Ask a doctor to submit the claims with the most specific billing and diagnostic codes possible. This increases the likelihood that at least part of a given treatment will be covered. For example, while the plan may not cover infertility treatment, it might cover treatment for a hormonal imbalance that causes infertility.
- Get help if necessary. Ask someone with health insurance expertise at the treatment center to talk to the billing coordinator at the insurance company.
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