Posted : 02/16/2012
You may dream of bringing a little one into the world. But if you have infertility issues, you must understand what your health insurance policy covers before seeking treatment, or you could face a financial nightmare.
More than 7 million women have infertility issues, according to the Centers for Disease Control and Prevention, but less than one-third of all states currently mandate that insurers cover infertility treatments.
And health insurance coverage can vary widely, depending on your employer and your policy. "It's not like an appendectomy," says Dr. Douglas Hadley, director of the policy coverage unit at Cigna.
Because of the huge variations in coverage, the best thing you can do is pick up the phone and call your insurer to learn the details of what's included in your particular policy. "Learn to be your own best advocate," says Mindy Berkson, an infertility consultant at Lotus Blossom Consulting in Chicago.
But before you start, have a list of specific questions you'd like answered, and then be prepared to take copious notes when you receive a reply. "The answers you get are only as good as the questions you ask," Berkson says.
Here are some of the key questions you should keep in mind.
Of the 15 states with infertility treatment mandates, there are major variations in coverage, according to the National Conference of State Legislatures (NCSL). Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia all mandate some type of coverage.
Although most of those states require that insurance coverage include in vitro fertilization (IVF), California, New York and Louisiana specifically exclude it.
There also may be exemptions if the law conflicts with the religious beliefs of an employer. For example, in Maryland, an insurer or employer may exclude the coverage if it conflicts with the religious beliefs and practices of a religious organization and the religious organization requests the exclusion, according to the NCSL.
Another example of an exclusion in a mandated state - again in Maryland - are regulations that became effective in 1994 that exempt businesses with 50 or fewer employees from having to provide IVF coverage.
A standard series of tests has been developed for males and females to determine why they can't conceive, and your health plan should detail which tests are included, Hadley says. Most health insurance policies cover the diagnostic phase.
Based on the results, a treatment plan is drawn up, Berkson says. Some insurance policies just cover the diagnostic testing to try to determine the root cause of infertility, but don't include coverage for treatment. "It's so unfair," says Berkson.
This can be the big stumbling block in fertility treatment. Hadley says the differences among policies are huge -- ranging from no treatment coverage to assisted reproductive technology, where eggs are removed from a woman, fertilized and then placed in the womb.
Berkson recommends getting your fertility treatment billing center involved to discuss the billing coding with your insurer. That way, you can make sure your health insurance covers the treatment recommended for you.
Things can change from year to year. Cigna, for example, has a team that reviews emerging technologies and decides whether to include them in its coverage if they are deemed safe and effective as compared to the treatments already in place, Hadley says. "It's very much of an evolving science."
Infertility treatment may carry hefty prices. The American Society for Reproductive Medicine says the average cost of an IVF cycle is $12,400.
If treatment is covered by your policy, you may face limits, such as being allowed only a certain number of IVF attempts. Or, you may have a financial limit, such as $25,000 for any standard treatment.
There also might be limits based on your age, or set by your employer. Even in a state where treatment is mandated, such as Rhode Island, the age limit for infertility treatment is capped at 42.
An insurer also may not cover more attempts if you've had one successful live birth, Berkson says.
This is another instance where it's important to know the coverage limits. RESOLVE: The National Infertility Association says IVF medications average $3,000 to $5,000 per cycle.
Certain drugs may be excluded, or there may be payment caps or co-pays, Hadley says.
You also may have to order your medications through an online pharmacy, Berkson says.
Once you know the answers to these questions, you'll be better prepared to make a decision as to how -- or whether -- to proceed.
You need to keep in mind "there could be a lot of out-of-pocket expenses, even with insurance coverage," Hadley says.
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