Mindy Berkson

Infertility and Health Insurance – Where to Start?

Infertility has become more of a concern for more hopeful couples as revolutions in medicine find more ways to treat the varied types if infertility. As more couples demand coverage for infertility more health insurance plans are covering more aspects of infertility treatment. The challenge can be finding out what that coverage is and how to file the claim so as not to have the claim rejected. Whether your plan is a HMO, PPO, POS, or Blue Cross / Blue Shield the bottom line is the same.

Know what treatments and drugs are covered and to what extent.

Here are some questions you should start with:

§ Is the benefit cycle based on a calendar year or fiscal year?

§ What is the pre designated treatment plan for those diagnosed as infertile?

§ Are there any waiting limits and/or preexisting condition limitations?

§ Do you have to be deemed infertile for a year, etc. before benefits kick in?

§ Are there any other exclusions to coverage that might affect you?

§ Can you use a discount pharmacy?

§ How does insurance cover expenses for third party help, such as a donor or surrogate? For example, does it cover medication for a donor or surrogate?

§ What is the appeals process?

Call the toll-free number listed on your benefits card and talk with a customer service representative. Be sure to write down their name, the time you called and the reference number of your conversation. Often, the first person you talk to may not be familiar with exactly where to find the correct information for you. Double check the answer. Call a second time, about a week later and at a different time. Ask the same questions and make sure the answers match. Ask your employer for a copy of the health plan contract which will list everything that is covered or rejected under the plan. You can also ask for a formulary, which lists all the drugs that are covered. Cross check these documents with the information your health insurance customer service representatives provided you.

So where do you go next if your plan doesn’t cover the infertility treatments you need?

If you are married or have partner benefits with your employer, call both and arrange to use benefits from whichever gives you the best coverage. Ask about how they would arrange coordination of benefits between you and your spouse. Make sure you find out if there are any differences in coverage between the primary holder and any dependents, as this may alter your decision to retaining your own coverage instead. Also, if you don’t get coverage for all aspects of treatment, consider saving the most expensive cycle for your insurance benefit. If you are close to an open enrollment period, you should consider reviewing benefits under each type of plan and switch if you find something that is better suited for your needs.

Sometimes, all of the information and technicalities can be overwhelming. When you get overwhelmed it is important not to give up. Find help, you do not have to do it alone. Don’t let infertility drive a wedge into your relationship. Don’t let the insurance companies decide what your infertility solutions are.

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