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Let's Talk about Insurance

a blog by Catherine Arizan, March 13, 2013

As anyone who has begun the process of treatment for infertility knows, navigating the complicated world of insurance coverage can be overwhelming. Mandated versus non-mandated states, deductibles, percentage co-pays … the factors that decide whether or not your treatment will be covered – and if so, how much - are almost infinite. The biggest factor that people overlook, however, is their employer.

As of this writing, 15 states have passed laws requiring insurance coverage for infertility treatment. There are two variations of the mandate: some states require coverage for infertility, while others require offering coverage for infertility. In states that have a “mandate to offer,” like California, your company must provide you with the option to select infertility coverage, but you’ll have to pay for it – in states like Massachusetts, which has a “mandate to cover,” infertility treatment must be covered as part of your benefit.

Each mandated state has its own set of requirements, limits, and exclusions: Connecticut, for example, covers a lifetime maximum of 2 in vitro fertilization (IVF) cycles. Maryland caps treatment for infertility at a $100,000 lifetime maximum. New Jersey requires patients to be less than 46 years of age, while Rhode Island covers patients who are between 25 and 40.

Here’s where your employer comes into play: some mandated states allow employees with certain numbers of employees to set up “Less than 25” and “Less than 50” plans, which are exempt from laws mandating infertility coverage - and in all 50 states, employers who self-insure are not required to provide infertility coverage, whether or not the company is located in a mandated state.

So what’s the difference between self-insured plans and fully insured plans, and why would an employer choose one over the other?

In a fully insured plan, the employer pays a per-employee premium to an insurance company, which in turn assumes the risk of providing the employee with coverage for insured events. In mandated states, fully insured plans follow state law where policy was written and therefore must provide coverage as defined by that state. In non-mandated states, fully insured plans are not required to provide infertility coverage, but may opt to do so (at the company’s discretion).

Companies with self-insured plans pay health care claims directly to providers such as physicians and obstetricians, instead of paying a per-employee premium. The employer can pick and chose which types of claims they are willing to pay. As treatment for infertility can become very costly, some employers choose to “carve out” – that is, not cover – such treatments. Of course, some employers chose to include coverage for infertility treatment in their plans.

When you begin researching insurance coverage for your treatment, the best place to begin is with your own individual insurance policy. Contact your plan and discuss your options in advance; your coverage may dictate which tests are covered and the kind of healthcare provider you can see.

If you find that your insurance policy does not provide coverage for infertility, prepare to investigate which aspects of your treatment may be covered under other parts of your policy. For example, certain medications (fertility drugs) prescribed by your physician for a full IVF cycle may be covered under your prescription insurance, rather than your medical insurance.

Finally, start researching resources for self-pay patients. There are many options out there – we’ll discuss some of them next month!

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