Understanding Insurance Coverage

Understanding Infertility Insurance CoverageNavigating insurance for infertility treatment coverage can be a confusing and daunting process. At RESOLVE New England, we offer a variety of educational resources to help you understand the insurance process. Below you will find information about the basics of health insurance as they relate to fertility treatment coverage. For additional information, consider ordering one of our Navigating Insurance Coverage Informational Packets or reading through our Insurance FAQ page.

Understanding Insurance Coverage Topics

How Infertility Benefits are Triggered

You must have a diagnosis of infertility in order to access the infertility benefits in your health plan. Be sure you are working with a Reproductive Endocrinologist (RE). Once batteries of diagnostic tests are complete, your RE will indicate if a diagnosis of infertility applies to you.

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Health Plan Types Defined

Health Maintenance Organizations Plans (HMO)

HMO plans provide benefits only within a specific network. Members are not covered for services incurred outside of the HMO network with the exception of emergency care. Most HMOs require members designate a Primary Care Physician (PCP) and obtain referrals for care from other providers.

Preferred Provider Organization Plans (PPO)

PPO plans offer both in and out-of-network benefits. Members’ out-of-pocket costs are lower in-network. Members do not need to designate a PCP or obtain referrals.

Indemnity Plans

Indemnity plans are insurance plans which offer their members the freedom to visit any practitioner that they wish to visit without having to have a referral. Members of these types of plans pay for the services that they receive up front and are reimbursed as specified in the terms of their plans. They typically cost more than the managed care plans noted above.

Qualified High Deductible Plan (often includes an HSA Plan)

Qualified High Deductible (qHDHP) plans meet specific guidelines set forth by the IRS that allow a Health Savings Account (HSA) to be offer alongside them. A qHDHP has an upfront deductible (2012 minimums are $1,200 Individual/$2,400 Family) that applies to all services with the exception of preventive services. A qHDHP can be on an HMO or PPO platform. A HSA is an individually owned, tax advantaged account that members can use for qualified medical expenses. Both employers and employees can contribute to an HSA.

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Fully Insured vs. Self-Insured Plans

In a fully insured plan, an employer pays the health insurer (i.e. HPHC, Tufts, BCBS) an established premium that is calculated by the insurance company to cover expected medical and drug claims and administrative costs. Fully insured medical plans are required by law to include state mandates for coverage, like infertility.

Under a self-insured or self-funded plan, the employer pays the costs for its employees’ health care directly instead of paying premiums to buy health insurance. Some self-insured employers hire insurance companies to process the paperwork and handle the claims. As a result, it is not easy to tell if a plan is self-funded. Contact your employer or your health plan to determine if your plan is self-insured. Self-insured health plans do not have to comply with the state mandated benefits, like infertility. The employer can choose to include them if they wish, but they are not required to.

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Who to Seek Out for Assistance

There are many people with whom you will interact during your treatment who can be valuable resources for navigating your insurance.

Your Clinic’s Insurance Coordinator

The Insurance Coordinator with your Clinic sees a lot of procedures approved and denied. They can be a key resource to you as you navigate through a health plan appeal or a health plan choice during open enrolment. Be clear though, that not all health plans are created equal. Your employer may have a very different plan design than another employer – even though they carry the same health plan like Harvard Pilgrim, Blue Cross or Tufts.

Your Employer’s Benefits Office

Your employer may have a Benefits Office within their Human Resources Department. The Benefits staff may, or may not, be familiar with plan design, and fully insured versus self-insured plan structures. The Benefits Office is governed by federal HIPAA regulations and will want to avoid discussing personal health situations.

It may be more efficient to talk directly with the health plan for these details. You will need the group number for the health plan your employer offers. Once you have the group number, call the health plan directly and access their plan expertise.

Your Health Plan’s Member Services

Each health plan has a Member Service Department that answers incoming calls from plan members, as well as non-plan members. They are trained to answer general questions about coverage and claims. As noted in the above section, calling the health plan directly for plan coverage questions, fully insured vs. self-insured status, as well as appeals procedures, is a helpful resource. Note – the Member Services Department staff are trained to ask you your name and ID number before they address your question. If you are not calling about a specific claim in process, but a general question, they don’t need your name. You are not required to identify yourself when asking a general question – feel free to explain that to them.

Note: if the member Services Department does not have the level of information you need concerning your claim, coverage for infertility or appeals, ask to speak with the Infertility Claims Unit/Specialist. These folks are trained at a much higher level regarding the nuances of coverage under the plan.

RESOLVE New England Insurance Advocate & Insurance Call-in Hours

RESOLVE New England makes available an Insurance Call-In Support Line for members every several weeks. Call in during the scheduled times and their Insurance Advocate will assist you with your insurance issues. See the best way to schedule a call with our insurance advocate.

Your Reproductive Endocrinologist (RE)

Your doctor is a key partner and advocate for you in the management of your care. If your RE suggests a particular treatment or protocol, and the health plan denies that procedure, be sure your RE works with you to appeal that denial.

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Additional Insurance Resources from RNE