state infertility laws

halfnhalf · January 2010

I was just looking at the laws re: infertility coverage, and while I feel like it's a really nice idea, I'm skeptical. I have a feeling that there are tons of loopholes, and I'm sure the states knows exactly how to work the system.

Has anyone actually qualified successfully for the coverage of expensive procedures like IVF in their state? I see that most states have pretty specific criteria that an individual must meet for IVF coverage. None that I saw listed PCOS, which I find strange b/c so many ppl w/PCOS have infertility and end up looking to IVF. Some states supposedly do cover ppl w/ endometriosis though.

I've never asked my doctor about my state's laws (it is on the list) but I probably should. If you aren't familiar with the laws I'm talking about, you can find them here: https://www.asrm.org/Patients/insur.html#OH

Anasara · January 2010

We're lucky enough to live & work in RI which is one of the few states that mandate IF coverage. Still, it's only 80% coverage. While I know that's better than nothing, I had a friend do several IVFs last year & they each ran her about $5k. DH & I don't exactly have that lying around; we'd have to save for IVF & may end up doing that later this year depending on my WTF appt tomorrow.

Even with the state mandates though, you are righ, places find loopholes. I know a girl from my local who works in MA works in a Catholic hospital & they didn't cover IF.

Jackie2200 · January 2010

We live in MD where there is a clear law. Unfortunately, there are loopholes and my company uses one of the loopholes. My husband is an attorney and we've even drafted strongly-worded letters to the state insurance commission. We could have a case since the law can be interpreted in 2 ways (one in favor of our situation) but we decided not to pursue it yet. Suing my employer in this economy is not a risk that we're willing to take and I wanted to focus on my health and sanity while TTC and not a legal battle.

I'll probably take on the cause in the future, with both my company and the state but not yet.

Jill070707 · January 2010

It's not the states that work the system, it's the insurance companies and/or companies choosing the insurance plans. For example, my last company in RI was based elsewhere, so we used that state's BCBS, so it was not covered.

Sorry if you knew this, I just had a fight with one of my cousin's friends regarding the Scott Brown issue on facebook because he thought the MA law means the state pays for my IF coverage. So I've seen the misconception and wanted to make sure.

AlissaCell701 · January 2010

I don't live in MA any more but have my heath insurance through the state still. There are definatly loopholes with the law. Like they won't pay of ICSI, Assisted Hatching and other "non needed proceedures". We were able to fight BCBS with the ICSI b/c H's count is slow low, but they need multiple SA's done and even a "face to face" conversation with my RE to get it covered. There is also a loop hole in that the state is only paying for 3 IVF cycles in a year.

That being said, I don't know if I would have been able to do IVF. I looked into what my insurance covered before starting this process because I knew we had a limit as to what we could spend OPP. You can read more on mandated IVF coverage here

https://www.metrowestdailynews.com/local_news/x960338982

https://www.asrm.org/Patients/insur.html

njohnson1972 · January 2010

I am in Texas, but my employer is in Illinois, so my insurance is out of Illinois. As it turns out, IL has mandated IF coverage, but you have to be an IL resident, which I am not.

In Texas, insurance companies are required to offer fertility treatments, but it is up to the employer to select that coverage. Then you have to have been trying for 5 years. It is stupid things like that make it difficult. I am 37 years old. I don't have 5 years to try on my own. I have a diagnosis - trying for 5 years isn't going to change my situation - only make it worse.

See, it is crap like this that pisses me off.

Anasara · January 2010

Jill070707:

It's not the states that work the system, it's the insurance companies and/or companies choosing the insurance plans. For example, my last company in RI was based elsewhere, so we used that state's BCBS, so it was not covered.

Sorry if you knew this, I just had a fight with one of my cousin's friends regarding the Scott Brown issue on facebook because he thought the MA law means the state pays for my IF coverage. So I've seen the misconception and wanted to make sure.

Here's the Scott Brown issue from the Resolve of the Bay State page:

https://www.resolveofthebaystate.org/MandateOverturnBill,PressRelease,1-11-10.pdf

kthappy76 · January 2010

It is a good idea, with lots of loopholes. Keep in mind the regs are on the insurance companies, but the application of them varies by employer. I live in IL (an IF mandate state), but since my husband's firm is self-pay (meaning they pay claims OOP and just pay the insurance co. a fee for their discounts) they have a cap on IF of $15K. My firm, which is based in Switzerland, is apparently not obligated to pay for IVF (they may be self-pay too), because they have a specific exclusion for this procedure in the policies options they offer. So the mandate by no means guarantees that residents are getting the coverages that are outlined in the mandate.

aplus816 · January 2010

I've successfully qualified for IVF in MA under two different insurance plans. MA does have one of the more comprehensive IF coverage mandates in the country, however. The extent of the coverage is determined by the individual policy. My first plan had a $15k lifetime max (a drop in the bucket when we're talking about IVF) and my current policy is unlimited.

There are certainly loopholes though. Companies that self fund their insurance policies do not have to provide IF coverage. Many larger companies are able to self fund.

I am incredibly thankful for my IF coverage on a daily basis. I wish that this was something that everyone facing this issue did not have to deal with.

Mrs.AmandaMqn · January 2010

njohnson1972:
I am in Texas, but my employer is in Illinois, so my insurance is out of Illinois. As it turns out, IL has mandated IF coverage, but you have to be an IL resident, which I am not.

In Texas, insurance companies are required to offer fertility treatments, but it is up to the employer to select that coverage. Then you have to have been trying for 5 years. It is stupid things like that make it difficult. I am 37 years old. I don't have 5 years to try on my own. I have a diagnosis - trying for 5 years isn't going to change my situation - only make it worse.

See, it is crap like this that pisses me off.

We currently live in Arkansas and it is one of the state mandated coverage states but when I brought that up, they told me that H's company is based in TX and falls under TX law. Their jaws dropped when I informed them TX had the same law. Stupid loopholes.

mrshoppy_1231 · January 2010

Thank you for that website. I had no idea some states had coverage for IF. I know there are loopholes and it doesn't apply to everyone - but I just had no idea! I wish I lived in one of them!

aplus816 · January 2010

AlissaCell701:

Like they won't pay of ICSI, Assisted Hatching and other "non needed proceedures".

this is a an issue with the application of the policy, not the mandate itself. I've had both of these procedures covered by insurance because of my dx.

glad you fought BCBS to get it covered though!

njohnson1972 · January 2010

This crap really makes my blood boil.

It is a medical condition. 1 in 8 couples have trouble conceiving.

And I recently switched employers - I had no coverage at my previous employer, so I knew it couldn't get worse. But of course, I can't ask those things while interviewing. Turns out, at least now I have drug coverage.

So even though this pisses me off, at least I am lucky enough to afford the procedures and I have some coverage. I know some of you have no help.

LCB34 · January 2010

Mrs.AmandaMqn:
njohnson1972:

I am in Texas, but my employer is in Illinois, so my insurance is out of Illinois. As it turns out, IL has mandated IF coverage, but you have to be an IL resident, which I am not.

In Texas, insurance companies are required to offer fertility treatments, but it is up to the employer to select that coverage. Then you have to have been trying for 5 years. It is stupid things like that make it difficult. I am 37 years old. I don't have 5 years to try on my own. I have a diagnosis - trying for 5 years isn't going to change my situation - only make it worse.

See, it is crap like this that pisses me off.

We currently live in Arkansas and it is one of the state mandated coverage states but when I brought that up, they told me that H's company is based in TX and falls under TX law. Their jaws dropped when I informed them TX had the same law. Stupid loopholes.

Texas does NOT have a mandate to cover IF. There is a mandate for insurance companies to offer the EMPLOYER (i.e. the company you work for) the chance to add IF coverage to their group policy. There is nothing stating the Employer has to add it in.

So, pretty much no one does.

halfnhalf · January 2010

Jill070707:

It's not the states that work the system, it's the insurance companies and/or companies choosing the insurance plans. For example, my last company in RI was based elsewhere, so we used that state's BCBS, so it was not covered.

Sorry if you knew this, I just had a fight with one of my cousin's friends regarding the Scott Brown issue on facebook because he thought the MA law means the state pays for my IF coverage. So I've seen the misconception and wanted to make sure.

Whoops, yes, I meant the insurance plans finding the loopholes despite the state's mandate, not the states finding the loopholes. People brought up a good point though - I guess it's not where you live, but where the employer is based. I wasn't sure about that. This stuff gives me a headache, it's so damn complicated and extremely frustrating...

AlissaCell701 · January 2010

aplus816:
AlissaCell701:

Like they won't pay of ICSI, Assisted Hatching and other "non needed proceedures".

this is a an issue with the application of the policy, not the mandate itself. I've had both of these procedures covered by insurance because of my dx.

glad you fought BCBS to get it covered though!

We fought them tooth and nail on the ICSI and won. The AH though wasn't as successful. My RE in FLA does it as part of there FET's and didn't consult my IS before hand. BCBS will only pay for it after 3 failed attempts. So we struck a deal with our RE's office and split it the cost ($1,000 total for Assisted H).

100% agree that there is an issue with the application of the policy. But if Senator Brown has anything to say, I think think the mandate might be history. I don't know though really how much power he has to change it. Can he just get rid of laws???

Yellow_Daisy · January 2010

CA doesn't really mandate much just 50% coverage of 6 - IUIs (procedure costs only, no BW, US, Meds) so a few hundred bucks off your IUI depending on what the RE charges. That said we have had no problems getting our insurance to approve the 50% cost. We just had to get an authorization from my OBGYN before seeing the RE, basically the same as any other specialist.

Now if the mandate covered something beyond IUIs I am sure it would be harder, but the cost for 50% of an IUI procedure is minimal. The real expense for us is the sperm, shipping, bw, us and meds.

But I count myself lucky to be saving a few hundred bucks because while 50% of the IUI procedure isn't that much it is something and that is more than most.

chickaboo1974 · January 2010

I am in Illinois, my DH's company is based in Illinois, however they are "self insured" which is a loophole in the Illinois law. However, I am very lucky that my DH's company does have a lifetime benefit for fertility- $20,000 plus extra for the meds. I am very lucky I know. Oh and I didn't need a referral to see the RE and I am skipping IUIs and going straight to IVF- to better manage my benefit.

psychmusetls · January 2010

i live in NJ and everything has been 100% covered. but we have a cap of 4 fresh IVFs, but unlimited FETs. but we have to pay freezing OOP.

halfnhalf · January 2010

psychmusetls:

i live in NJ and everything has been 100% covered. but we have a cap of 4 fresh IVFs, but unlimited FETs. but we have to pay freezing OOP.

That's wonderful. You are really lucky! But isn't that moreso related to your insurance plan, and not the state of NJ?

njohnson1972 · January 2010

LCB34:
Mrs.AmandaMqn:
njohnson1972:

I am in Texas, but my employer is in Illinois, so my insurance is out of Illinois. As it turns out, IL has mandated IF coverage, but you have to be an IL resident, which I am not.

In Texas, insurance companies are required to offer fertility treatments, but it is up to the employer to select that coverage. Then you have to have been trying for 5 years. It is stupid things like that make it difficult. I am 37 years old. I don't have 5 years to try on my own. I have a diagnosis - trying for 5 years isn't going to change my situation - only make it worse.

See, it is crap like this that pisses me off.

We currently live in Arkansas and it is one of the state mandated coverage states but when I brought that up, they told me that H's company is based in TX and falls under TX law. Their jaws dropped when I informed them TX had the same law. Stupid loopholes.

Texas does NOT have a mandate to cover IF. There is a mandate for insurance companies to offer the EMPLOYER (i.e. the company you work for) the chance to add IF coverage to their group policy. There is nothing stating the Employer has to add it in.

So, pretty much no one does.

That's what I said Confused

BTW, Hewlett Packard does have IF coverage. Met a chatty woman in the waiting room who is cycling with me. She works for HP and has coverage.

LCB34 · January 2010

njohnson1972:
LCB34:
Mrs.AmandaMqn:
njohnson1972:

I am in Texas, but my employer is in Illinois, so my insurance is out of Illinois. As it turns out, IL has mandated IF coverage, but you have to be an IL resident, which I am not.

In Texas, insurance companies are required to offer fertility treatments, but it is up to the employer to select that coverage. Then you have to have been trying for 5 years. It is stupid things like that make it difficult. I am 37 years old. I don't have 5 years to try on my own. I have a diagnosis - trying for 5 years isn't going to change my situation - only make it worse.

See, it is crap like this that pisses me off.

We currently live in Arkansas and it is one of the state mandated coverage states but when I brought that up, they told me that H's company is based in TX and falls under TX law. Their jaws dropped when I informed them TX had the same law. Stupid loopholes.

Texas does NOT have a mandate to cover IF. There is a mandate for insurance companies to offer the EMPLOYER (i.e. the company you work for) the chance to add IF coverage to their group policy. There is nothing stating the Employer has to add it in.

So, pretty much no one does.

That's what I said

BTW, Hewlett Packard does have IF coverage. Met a chatty woman in the waiting room who is cycling with me. She works for HP and has coverage.

I was replying to Amanda's comment that Texas had a mandate - your post just ended up in there too!

njohnson1972 · January 2010

LCB34:
njohnson1972:
LCB34:
Mrs.AmandaMqn:
njohnson1972:

I am in Texas, but my employer is in Illinois, so my insurance is out of Illinois. As it turns out, IL has mandated IF coverage, but you have to be an IL resident, which I am not.

In Texas, insurance companies are required to offer fertility treatments, but it is up to the employer to select that coverage. Then you have to have been trying for 5 years. It is stupid things like that make it difficult. I am 37 years old. I don't have 5 years to try on my own. I have a diagnosis - trying for 5 years isn't going to change my situation - only make it worse.

See, it is crap like this that pisses me off.

We currently live in Arkansas and it is one of the state mandated coverage states but when I brought that up, they told me that H's company is based in TX and falls under TX law. Their jaws dropped when I informed them TX had the same law. Stupid loopholes.

Texas does NOT have a mandate to cover IF. There is a mandate for insurance companies to offer the EMPLOYER (i.e. the company you work for) the chance to add IF coverage to their group policy. There is nothing stating the Employer has to add it in.

So, pretty much no one does.

That's what I said

BTW, Hewlett Packard does have IF coverage. Met a chatty woman in the waiting room who is cycling with me. She works for HP and has coverage.

I was replying to Amanda's comment that Texas had a mandate - your post just ended up in there too!

Ok. I was kinda confused. I even re-read it to make sure I typed correctly what I was thinking!

Mrs.AmandaMqn · January 2010

Yep, I know the law in TX doesn't mandate coverage.

Temp984666312503071 · January 2010

Yes.

I live in Maryland which mandates infertility coverage. My insurance (through the school division I work for) provides infertility coverage up to $100,000. They will do 3 fresh IVF cycles (and all FETs) and if you have a live birth will do another 3 fresh until you exhaust the $100,000 lifetime coverage.

The "loopholes" are that you have to be under a certain age (40?), married at least 2 years, and have a diagnoses (they will take "unexplained" but you have to try for at least one year). You also can't have "artificial" infertility (eg: tubes tied, vasectomy in the past).

They paid for my entire infertility work-up, IVF and ICSI. The only thing they don't pay for was to freeze embryos or store them (which I wouldn't expect). I am 28, have been married for 6 years, and had been trying for 18 months (with one miscarriage) when I did IVF.

psychmusetls · January 2010

halfnhalf:
psychmusetls:

i live in NJ and everything has been 100% covered. but we have a cap of 4 fresh IVFs, but unlimited FETs. but we have to pay freezing OOP.

That's wonderful. You are really lucky! But isn't that moreso related to your insurance plan, and not the state of NJ?

i count myself really blessed! but no, my insurance is the minimum for mandated coverage. However, that coverage is mandated only for employers who insure more than 50 people. Also, if you are a health care professional, the healthcare system you are employed by may offer their "insurance" . .. . so there are situations that you may not qualify for the coverage.

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