Insurance? Nevermind, You have Infertility

Chris – Let’s say you are walking, and you step on a rusted old sign post that looks like it was gnawed off by a rabid badger, it cuts your foot and you quickly soak your flip flop with a strange red substance that is apparently really important to keep inside you (true story). What do you do? You wait for your wife to get the car to take you to a Doc-in-a-box, get a medical boot, a tetanus shot, and sent on your way.  When it comes time to pay for all of these services, guess what, you don’t pay full price. The insurance company swoops in, says they are only going to allow a charge of $50 instead of $6 billion, then they pay $40 of it so at the end of the day, you only pay $10.  With that being the cost, who wouldn’t want to step on that rusty road sign post?

Although that is the way it works for mainstream, common medical issues, somehow insurance companies have managed to work the legal system such that they can openly exclude any fertility treatments under the premise that this is not a medical condition and any procedures are “elective.”  It’s funny right?  Infertility is not a medical condition and us trying desperately to conceive a child is an elective procedure?  As a slight digression, let me say that we, the IF community, are not alone in this.  How about breast cancer survivors?  They have a full mastectomy to remove all of the cancerous tissues, BUT if they want to get an implant to replace the tissue that was removed, they have to pay out of pocket.  For some insurance companies, this is considered “elective.”  Sucks right?  So how do the insurance companies sneak this past all of the watchdog organizations looking to protect our rights?

It must have something to do with the still present, incredible disconnect between physical and mental health.  For the breast cancer survivor, the insurance companies can claim (and are successful) in saying that this is just what she wants and isn’t necessary.  They neglect the fact that, perhaps, the implant would aid in her recovery, take away some insecurity that she may face getting back into the world.  Who knows, maybe by addressing her mental health through getting the implants, it could have a synergistic impact on her physical health … now there is a novel thought!  I think the same is true for us IF’ers.  The insurance companies can readily say that, “Well, if having a family is so important, they can just adopt or something.”  Beyond infertility being a disease, they don’t realize the holistic impact that this has on us.  Not to mention the fact that all of the poking and prodding that was done to Candace is part of how we found out that she has the precancerous cells for uterine cancer.  No, I don’t think there is anything that should be classified as “elective” about infertility and the treatment options to combat it.

Candace and I were lucky though.  Even though we don’t live in one of the 15 states that protects their citizen’s rights to insurance coverage for fertility treatments (see the list and limitations here), our insurance company did cover some treatments.  I will leave it to Candace to cover the details of that.  Suffice it to say, it did not cover anywhere near everything and we could certainly have used much better insurance coverage.  That being said RESOLVE has been an advocate for addressing this issue with insurance coverage and has a number of very informative articles on that subject.

Enough of my rant, Candace is going to give you some tips for how to find out what your insurance coverage is and what to do with that information. 

Candace – This is another stage in your path to parenthood that seems to work against you.  You or your partner have this horrible disease called infertility.  Yes ***GASP*** it is actually a medical condition!  Not just some “It’s all in your head or trying too hard” problem.  You find out you have fried eggs and disoriented sperm with no compass.  After trying for what seems forever, you realize hmm … we might have a problem.  Turns out fertility treatments are expensive.  Money is the numero uno road block in preventing couples from working on building their family.  It could be a simple surgery or even someone getting ready to battle cancer that would like to freeze their eggs or sperm in order to have a chance at a family one day.  There are only 15 US states (out of 50 in case you failed US geography) that mandate some-ish kind of fertility coverage.  We were lucky, not only do we live in a state where insurance coverage is not mandated, but we had a $10,000 insurance cap.  This can go a long way if you don’t use it for the crazy-inducing meds you will be injected.  We paid out of pocket for those.  Even though we had coverage, at this point in our still childless pilgrimage, we are in the hole $60,000 out of pocket.  For the sake of your mental stability and psychiatrist bill, best not to spend time thinking of all the great vacations, new house, and other material things you could have afforded with that money.  I can tell you though, Chris and I sat on the floor and spent countless hours scouring every policy we could pick from and still came up short of any kind of complete coverage for fertility treatments.

Here are some Tips and Tricks for navigating insurance coverage for infertility treatments.

1.  Do your research!  First things first, find out if you live in a state that mandates infertility coverage.  It may not cover all of the big ticket items, but something is better than nothing.

2.  Before seeing your RE, make sure if you do have coverage. Even if it is the bare bones policy, get your pre-certification/pre-authorization letter from your insurance provider.

3.  Get a copy of the 800+ page encyclopedia of your insurance companies coverage to start dissecting.  You company may provide a brief synopsis of deductibles and coverages.  You don’t need this.  You need the full monty, the complete list of coverages and exclusions.  You may have to reach out directly to your insurance provider or your HR to obtain this.

4.  If you have an insurance cap, use the money wisely.  For example, for a treatment that will “cost” $5000, your insurance will pay them an “adjusted” rate of $1000.  Medication though, is a whole different story.  If the cost is $3000, your insurance company will pay $3000 not a negotiated lower rate.  See that?  Fuzzy math but it makes your insurance dollar go much further if it is for procedures instead of medications … in most cases. 

5.  Does your insurance say it is specifically exclusive of fertility treatments?  If you do not see a specific exclusion on infertility coverage, diagnosis, medications, etc., then the company must cover it.  They must cover anything they don’t specifically exclude.  It’s rare because they have fancy lawyers and red-tape personnel to comb through that, but do your homework.

6.  Once you have put your exclusions under the microscope, take a gander at the section related to pregnancy or infertility.   You may find that, although hidden and lost in a wordy boring document, they have limited coverage on infertility treatments.  Sneaky insurance companies! 

7.  Although extreme, there is the Americans with Disabilities Act (ADA) or Equal Employment Opportunities Commission (EEOC).  Maybe your employer can be persuaded through that avenue.  Insurance companies will argue this point, but infertility can be classified as a disability.

At the end of all of the paperwork, stalker-style phone calls and research, you will be the one ultimately responsible for knowing your insurance coverage for infertility.  If you are hitting brick walls, try out these paths first:

1.  Go directly to the insurance companies.  Some even have a fancy-pantsy Reproductive Resource Services department.

2.  Make friends with your HR rep.  Even if you are not entirely open about your baby-making woes, you need to share with them.  They can help guide you.

3.  Your potential clinic will also help you.  They can help dissect your police and give you the “ins” on the right questions to ask (ours did!).

4.  OK, I did not know about this until I started researching for this post, but damn this would have come in handy!  Fertility Lifelines, is a resource provided to help answer your insurance questions in layman’s terms.  1-866-LETS-TRY <- sorry that’s just funny to me.  It is (1-866-538-7879).

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