IVF Insurance, mandates, OOP, etc

starspangledgirl1 · January 2013

Just curious ladies, does your state have a IVF mandate or not? If yes, about how much do you pay per cycle? If not, what is the required mandate in your state? (unlimited, limited, etc)

DebateThis · January 2013

IL is a mandate state. The text of the mandate I have C&P'ed below, but from what my clinic has said, it seems pretty common for companies to use loopholes in language to get out of covering as much as possible. I am very thankful that my company adheres to the text of the mandate completely but I'm a little uncomfortable talking about exactly what they cover.

llinois law requires insurance companies and HMOs to provide coverage for infertility to employee groups of more than 25. The law does not apply to self-insured employers or to trusts or insurance policies written outside Illinois. However, for HMOs, the law does apply in certain situations to contracts written outside of Illinois if the HMO member is a resident of Illinois and the HMO has established a provider network in Illinois.

Eligibility

To receive infertility coverage, you must:

Live in Illinois,
Be covered by a fully insured Illinois group policy through an employer with more than 25 full-time employees, and
Have been unable to conceive after one year of unprotected sexual intercourse between a male and female or have been unable to sustain a successful pregnancy

Covered Expenses

Illinois requires group insurance and HMO plans to cover the diagnosis and treatment of infertility the same as all other conditions. For example, unique co-payments or deductibles cannot apply to infertility coverage. Benefits shall include, but not be limited to:

Testing
Prescription drugs
Artificial insemination
Invitro fertilization (IVF)
Gamete intrafallopian tube transfer (GIFT)
Intracytoplasmic sperm injection (ICSI)
Donor sperm and eggs (medical costs)
- Procedures utilized to retrieve oocytes or sperm and subsequent procedures used to transfer the oocytes or sperm to the covered recipient are covered
- Associated donor medical expense, including but not limited to physical examination, laboratory screening, psychological screening, and prescription drugs, are covered if established as prerequisites

Limitations

Benefits for advanced procedures such as IVF, GIFT, ZIFT or ICSI are required only when a successful pregnancy through reasonable, less costly medically appropriate infertility treatments for which coverage is available under the policy is not successful.

The benefits for advanced procedures required by the law are four completed oocyte retrievals per lifetime of the individual, except that two completed oocyte retrievals are covered after a live birth is achieved as a result of an artificial reproductive transfer of oocytes. For example, if a live birth takes place as a result of the first completed oocyte retrieval, then two more completed oocyte retrievals for a maximum of three are covered under the law. If a live birth takes place as a result of the fourth completed oocyte retrieval, then two more completed oocyte retrievals for a maximum of six are covered. The maximum number of completed oocyte retrievals that can be covered under the law is six.

One completed oocyte retrieval could result in many IVF, GIFT, ZIFT or ICSI procedures. There is no limit on the number of procedures, including less invasive procedures such as artificial insemination. The only limitations are on the number of completed oocyte retrievals.

Once the final covered oocyte retrieval is completed, one subsequent procedure (IVF, GIFT, ZIFT, or ICSI) used to transfer the oocytes or sperm is covered. After that, the benefit is maxed out and no further benefits are available under the law.

Oocyte retrievals are per lifetime of the individual. If you had a completed oocyte retrieval in the past that was paid for by another carrier, or not covered by insurance, it still counts toward your lifetime maximum under the law.

Exclusions

Your group insurance or HMO plan does not have to pay for:

Costs incurred for reversing a tubal ligation or vasectomy
Costs for services rendered to a surrogate, however, costs for procedures to obtain eggs, sperm or embryos from a covered individual shall be covered if the individual chooses to use a surrogate and if the individual has not exhausted benefits for completed oocytes retrievals
Costs of preserving and storing sperm, eggs and embryos
Costs for an egg or sperm donor which are not medically necessary; any fees for non-medical services paid to the donor are not covered under the law
Experimental treatments
Costs for procedures which violate the religious and moral teachings or beliefs of the insurance company or covered group

Permissible Exclusions

Reversal of voluntary sterilization; however, in the event a voluntary sterilization is successfully reversed, infertility benefits shall be available if the covered individual's diagnosis meets the definition of "infertility".
Payment for services rendered to a surrogate (however, costs for procedures to obtain eggs, sperm or embryos from a covered individual shall be covered if the individual chooses to use a surrogate);
Costs associated with cryo preservation and storage of sperm, eggs, and embryos; provided, however, subsequent procedures of a medical nature necessary to make use of the cryo preserved substance shall not be similarly excluded if deemed non-experimental and non-investigational;
Selected termination of an embryo; provided, however, that where the life of the mother would be in danger were all embryos to be carried to full term, said termination shall be covered;
Non-medical costs of an egg or sperm donor;
Travel costs for travel within 100 miles of the insured's or member's home address as filed with the insurer or health maintenance organization, travel costs not medically necessary, not mandated or required by the insurer or health maintenance organization;
Infertility treatments deemed experimental in nature. However, where infertility treatment includes elements which are not experimental in nature along with those which are, to the extent services may be delineated and separately charged, those services which are not experimental in nature shall be covered.

No insurer or HMO required to provide infertility coverage shall deny reimbursement for an infertility service or procedure on the basis that such service or procedure is deemed experimental or investigational unless supported by the written determination of the American Society for Reproductive Medicine (formerly known as the American Fertility Society or the American College of Obstetrics). These entities will provide such determinations for specific procedures or treatments only and will not provide determinations on the appropriateness of a procedure or treatment for a specific individual.

Coverage is required for all procedures specifically listed in Section 356m of the Illinois Insurance Code, entitled Infertility Coverage [215 ILCS 5/356m], regardless of experimental status;
Infertility treatments rendered to dependents under the age of 18.

Everycol0r · January 2013

Texas only requires insurance companies to offer infertility treatment, so a company has a choice to accept the rider or decline it. 95 decline it because it adds more to the premium.

ball.and.chain · January 2013

Check out www.ncsl.org. I'm on my phone so can't send you a direct link easily, but if you go under the Issues and Research tab, then Health, you can find a summary of state IF laws.

It's not just about your state laws but also your insurance policy. I have very very good insurance, and as far as I can tell they have covered above and beyond any if the applicable state laws I live in MA, work for a NY company, with a CT insurer. All are mandated states. I paid 80 in drug copays, otherwise IVF cost me nothing.

new+tothis · January 2013

My state is not mandated and they pay absolutely nothing. I'm 100% OOP.

BootsOrHearts · January 2013

I'm in NC which is not a mandated state, but I beleive my insurance policy does have some fertility coverage.

As a PP said, it's not only your state, but what your insurance policy specfiically says. You can't go by companies either - humana covers it, blue cross doesn't, etc. because every policy for every company is a little different. If your company is self-insured, then THEY decide and not the insurance company, what benefits to cover and what not to cover.

Edit: spelling

DebateThis · January 2013

BootsOrHearts:
I'm in NC which is not a mandated state, but I beleive my insurance policy does have some fertility coverage.
As a PP said, it's not only your state, but what your insurance policy specfiically days. You can't go by companies either - humana covers it, blue cross doesn't, etc. because every policy for every company is a little different. If your company is self-insured, then THEY decide and not the insurance company, what benefits to cover and what not to cover.

Where in NC??

Temp878586125009588 · January 2013

We have state mandated IF coverage. Our coverage is 50/50 on injectables and 50/50 on anything that is part of the procedure. So, if my office is charging $8,000 for the IVF, not including meds, we pay $4,000 the insurance pays $4,000, same goes for the injectable meds. All oral medication is covered though our prescription plan. Also, we only have 3 attempts of IVF, (Which, my insurance counts FET's as an IVF cycle), per live birth with I think a $100,000 cap.

Temp878586125009588 · January 2013

BootsOrHearts:
I'm in NC which is not a mandated state, but I beleive my insurance policy does have some fertility coverage.
As a PP said, it's not only your state, but what your insurance policy specfiically days. You can't go by companies either - humana covers it, blue cross doesn't, etc. because every policy for every company is a little different. If your company is self-insured, then THEY decide and not the insurance company, what benefits to cover and what not to cover.

Also, this is extremely true. One company will be different from the next, not just insurance, but who you work for.

Everycol0r · January 2013

Of you're state doesn't mandate it, you're employer chooses if IVF is covered or not. Not the insurance company, most of them offer it as a rider extra but it makes you're premium go up.

oO Angie Oo · January 2013

I'm in CA and I don't believe we are a mandate state because my husbands insurance does not cover infertility treatments but then by the grace of God I found out the insurance at my work does. I am covered for up to 6 cycles of IUI and a lifetime max of 3 cycles of IVF. So thankful.

waknsno007 · January 2013

oO Angie Oo:
I'm in CA and I don't believe we are a mandate state because my husbands insurance does not cover infertility treatments but then by the grace of God I found out the insurance at my work does. I am covered for up to 6 cycles of IUI and a lifetime max of 3 cycles of IVF. So thankful.

Angie, which insurance company do you have, if you don't mind me asking? My husband and I just switched over to Kaiser because they cover infertility, but then we found out that they do not cover IVF. The link that PP gave stated that insurance companies in CA are not required to cover IVF, so I'm really interested to see which companies choose to cover it. Good luck to you and I'm so happy your insurance covers it!

BTW, I'm a first-time poster on this board, just started following it today. I feel so much better seeing all the support everyone offers each other!

KariAnnM 23 · January 2013

My state (Alabama) does not mandate it and I have not heard of any company around here that even offers coverage. My secondary insurance (state education) does cover IUI's. The down part is that I didn't get my teaching job until we had decided to move to IVF.

jschwind22 · January 2013

I live in IL where there is a mandate, but like Debatethis mentioned the insurance company that we have has found a loop hole. We only have coverage up until the diagnosis. This is new insurance for us as of 1/1/13. Prior to that we had the IL mandate coverage.

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IVF Insurance, mandates, OOP, etc

Re: IVF Insurance, mandates, OOP, etc

Eligibility

Covered Expenses

Limitations

Exclusions

Permissible Exclusions

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