Frequently Asked Questions About Insurance

Frequently Asked Questions about Infertility Insurance Here is a list of the ten most common questions we receive regarding health insurance and infertility treatment coverage. Answers to these frequently asked questions have been prepared by RESOLVE New England’s Insurance Advocate, Marymichele Delaney. Click on any of the questions below to learn more.

Additional Insurance Resources from RNE

Top 10 FAQ About Insurance & Infertility

 

  1. Are there employers that do not have to comply with the Connecticut, Massachusetts or Rhode Island mandates for infertility benefits?
  2. If I live in Massachusetts, but my employer is out-of-state and has out-of-state coverage, am I covered by my state’s mandate?
  3. Are experimental procedures, surrogacy or reversal of voluntary sterilizations covered by the Massachusetts insurance mandate?
  4. What other medical practices have a similar cost to infertility expenditures?
  5. In a job interview, how do I learn about the infertility benefits under their medical plan?
  6. How do I know if my plan is fully insured or self-insured?
  7. My employer offers a Flexible Spending Account (FSA) for health care expenses. Can I use this account for my infertility out of pocket expenses?
  8. If my procedure has been denied, how do I frame the appeal process?
  9. Should I hire an attorney to help me write my appeal letter if I have a denied procedure?
  10. When writing an appeal, what is the general tone the communication should take?
Are there employers that do not have to comply with the Connecticut, Massachusetts or Rhode Island mandates for infertility benefits?

Yes. In Connecticut, religious organizations are not required to offer coverage and self-insured employers are exempt from the mandate. In Massachusetts, self-insured employers small businesses, (generally with less than 26 employees), and diocese-related entities (parochial schools, churches, hospitals) do not have to comply with the mandate. In Rhode Island, religious organizations are not required to offer coverage and self-insured employers are exempt from the mandate.

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If I live in Massachusetts, but my employer is out-of-state and has out-of-state coverage, am I covered by my state’s mandate?

Technically yes, but out-of-state employers and health plans often do not comply with the requirement to include MA-mandated benefits for their employees living or working in MA. There is no active jurisdiction for compliance and the out-of-state employers know that. The MA Division of Insurance has indicated that a resident of MA, regardless of his or her location of employment, is entitled to receive infertility coverage.

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Are experimental procedures, surrogacy or reversal of voluntary sterilizations covered by the Massachusetts insurance mandate?

No – experimental procedures, surrogacy or reversal of voluntary sterilizations are not covered by insurance mandates in Massachusetts.

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What other medical practices have a similar cost to infertility expenditures?

The cost of infertility, based on the Journal of Reproductive Medicine, is similar to the cost of nutrition and podiatry; much less expensive than the cost of physical therapy. This is generally due to the fact that a very small percentage of the infertile population chooses to do assisted reproductive technologies (ART) even when covered by their health plan.

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In a job interview, how do I learn about the infertility benefits under their medical plan?

You don’t want to ask specific benefit questions in an interview. You can ask for their general benefit plan information; scour the employer’s website to see if there are details on the medical plan there—many times there are. Then, call the insurance carrier(s) for that employer, and ask them the specifics of the infertility benefit under that employer’s group plan.

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How do I know if my plan is fully insured or self-insured?

Ask your employer’s Benefits/Human Resources Office. They may not know, in which case you should call the insurance carrier, provide them with the group number for the plan you are in, and ask them. If they are self-insured, they may still cover the infertility mandate—ask them that question specifically.

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My employer offers a Flexible Spending Account (FSA) for health care expenses. Can I use this account for my infertility out of pocket expenses?

Yes, you should use the FSA for any out of pocket costs you will have due to your infertility care, (or any other health care eligible expenses). This is a great way to save on taxes, since you pay no taxes on the money from your FSA, as long as it is used for eligible health care expenses. The maximum allowed under these plans is set by the IRS. Ask your Benefits Office for more details.

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If my procedure has been denied, how do I frame the appeal process?

Some key points to be aware of as you frame an appeal:

  • Draft you appeal letter to target specifically the reasons listed in the denial letter from the insurance company;
  • Be familiar with the appeal process and time-line that your insurance company has established;
  • Have your RE write a supporting letter that will accompany your appeal letter – make it easy for your RE to participate (draft the letter you want him/her to write on your behalf);
  • Do not be emotional in the appeal letter, do not discuss your difficulty journey of infertility, keep the focus fact-based;
  • Use your Clinic’s Insurance Coordinator for additional data that may be useful from your file;
  • Tell the insurance carrier you want to be present at the review hearing;
  • Remember – the infertility mandate in CT, MA and RI is general; it allows the insurance companies to set reasonable guidelines for infertility benefits. If the standards the insurance company has set are not reasonable for your situation – indicate that and the reasons why;
  • Whenever you have data that supports your case – use it;
  • You have nothing to lose by appealing a denied procedure.
  • If the procedure is still denied after appeal, do the next level of appeal through the Office of Patient Protection.

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Should I hire an attorney to help me write my appeal letter if I have a denied procedure?

Generally, you will not find many attorneys who do this type of work because it is time-consuming for them, and the rate of return is just not that profitable. A better strategy is to save your money and use the resources from this web site, as well as the Insurance Advocate Call-In Support Line offered to RESOLVE New England members for guidance and strategy in framing your appeal.

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When writing an appeal, what is the general tone the communication should take?

Write the appeal from the perspective that the insurance carrier made a mistake in denying the procedure, and they did not have all the facts to make the correct decision – which is to approve the procedure. It is important to approach the appeal from a perspective of mutual cooperation. Pulling an attorney into the process will make the insurance company potentially confrontational vs. cooperative.

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