Question about IF insurance coverage

lebradford · June 2014

So we made the massive mistake of purchasing an insurance policy through a brand new insurance company that was formed at the beginning of the year due to the affordable healthcare act. We are extremely lucky to live in IL where there is mandated infertility coverage, but I'm pretty sure we are the company's first infertility claims, and they have literally no idea what they are doing. I could rant all day long, but I have a few practical questions for those of you who have infertility coverage or know anything about it.

We don't meet their definition of infertile because we haven't been trying for a full year (even though I'm not ovulating). Our year is up in September, and in theory, we will have coverage then. In the meantime, we are paying for treatment OOP. I believe we have met out OOP max for the year, and we would like to cram as much IF treatment in the September-December time period that we still have this insurance. I'm trying to figure out from them what requirements they have for when they will cover injects or IUI. Like, do you have to try oral meds for a certain period of time first? Do they only cover IUI for MFI or after a certain # of TI attempts? My big question is about IVF. I want to know what requirements they have before they'll cover IVF. It does not specify in the plan document. The answer to this could directly impact how many cycles we pay OOP for in the meantime. For example, if you need 2 injects cycles before IVF, then we'll pay 2 injects cycles OOP before September, and then go straight to IVF. It is important that I figure this out before August/September when we submit the pre-approval paperwork.

I know you guys don't know about my specific insurance, but I was wondering if you could tell me how a normal insurance company runs things? Do they specify these things in writing? What kinds of requirements have you had to meet before IVF is covered? Any other thoughts about how I can get this figured out quickly and cover my own ass? I called them today and the lady said all they had was the plan document, but it is so vague, there has to be more information than that! A supervisor is supposed to call me back, but it could be a few days. My husband has talked to this supervisor numerous times, and I'm worried I won't get a specific answer out of him either.

Here are some highlights from the plan document:

Benefits will be provided the same as your benefits for any other condition for Covered Services rendered in connection with the diagnosis and/or treatment of infertility...Infertility means the inability to conceive a child after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy....Benefits for treatments that include oocyte retrievals will be provided only when:You have been unable to attain or sustain a successful pregnancy through reasonable, less costly, medically appropriate infertility treatments....

There's more there, but what does "through reasonable, less costly...treatments" even mean?!

Sorry for my rant. :-( I don't know what to do. Any advice would be appreciated.

lebradford · June 2014

amylev80 said:

lebradford said:

There's more there, but what does "through reasonable, less costly...treatments" even mean?!

I would imagine that this statement refers to covering IUI versus IVF or using medicated TI versus IUI. Who the hell knows.... I think insurance companies do this on purpose, so they can get out of paying claims. I don't live in a state with IF coverage, but my clinic is nice enough to code what they can under a PCOS diagnosis, and not an IF diagnosis, because we have no IF coverage.

I have no other help, but send big 'ol squishy hugs...and wine.

@amylev80 Yes, I agree with you. And I think that makes sense. But you would think it would be very specific about what a reasonable amount of trying something else is. Like, is it 3 IUIs?? Specifics would be great here. :-p

And, thanks! I will take your hugs and ALL the wine! ;-)

LindseyM2012 · June 2014

https://insurance.illinois.gov/HealthInsurance/infertility.asp

Check out this link. I am also from Illinois so I am looking into my insurance coverage of IF treatments too! It scares me how expensive it may be. This site says IL insurances need to cover IVF and other treatments. According to this,

"Any woman who receives coverage under a fully-insured group policy of accident and health insurance or HMO contract for a group larger than 25 who:

1) Is unable to conceive after one year of unprotected sexual intercourse;

2) Is unable to sustain a successful pregnancy;

3) Has been diagnosed by a physician as having a medical condition that renders conception impossible through unprotected sexual intercourse; or

4) Has undergone one year of medically based and supervised methods of conception, including artificial insemination, which a physician has determined to have failed and are not likely to lead to a successful pregnancy.

NOTE: Each of these four categories of infertility is independent of the other. For example, if a physician determines that one year of artificial insemination has failed and is not likely to lead to a successful pregnancy a woman shall be considered infertile for purposes of this coverage, regardless of whether she satisfies any of the other three categories of infertility."

lebradford · June 2014

Thanks, @LindseyM2012‌! That's pretty much exactly what my plan document says, but that phone number could be really helpful if I can't get a straight answer from my insurance company about what constitutes a reasonable attempt with cheaper methods.

Kcheese · June 2014

I asked my insurance to mail me a "detailed benefits summary." I actually had to request it twice as they did not want to give it to me. I have no infertility benefits, but wanted to see if anything might be covered under another benefit. Also, if you call & get any information over the phone write down exactly who you spoke to & exactly what they said. Every time I called I would get a different response for what might be covered. If you can get anything in writing it's best, but most of the time they won't give it to you unless it is a pre-authorization. Much of the terminology insurance companies use is non specific or per "medical necessity guidelines" which gives them a lot of wiggle room.

lebradford · June 2014

Kcheese said:
I asked my insurance to mail me a "detailed benefits summary." I actually had to request it twice as they did not want to give it to me. I have no infertility benefits, but wanted to see if anything might be covered under another benefit. Also, if you call & get any information over the phone write down exactly who you spoke to & exactly what they said. Every time I called I would get a different response for what might be covered. If you can get anything in writing it's best, but most of the time they won't give it to you unless it is a pre-authorization. Much of the terminology insurance companies use is non specific or per "medical necessity guidelines" which gives them a lot of wiggle room.

Thanks! I'll asked about a detailed benefits summary. I've never heard of that before. I definitely will get the person's name and ID #. My goal is to get them to give me something in writing, but I have a feeling they're going to avoid doing that at all costs.

I want to see if they will give me a pre-approval for a September cycle now (or in August at least) so we know ahead of time what they will or will not cover. It's like, if I have to wait for the year mark to apply for the pre-approval, the calendar year could be up before they bother responding. The lady said that was possible, but I'm not sure if I can trust her. I don't think she knew what she was talking about.

BunnyBerry · June 2014

Sounds like they will make your RE defend his/her decisions to move to more invasive treatments, probably by attempting a research-supported number (3?) of something before moving on.

Hopefully they will be more flexible than that.

Glad you do have mandated coverage...do you have the option of switching providers next year if needed?

ETA: By mandated coverage I meant the required infertility/IVF coverage of your state, not a politically charged statement about new healthcare rules, sorry!

lebradford · June 2014

@BunnyBerry‌

Unfortunately they haven't cared in the past what my RE recommended. He recommended treatment earlier than a year because I wasn't ovulating at all, and they disagreed and denied our claim.

I understand that (to a point) but it puts me in the scary situation where I don't think they care what my doctor thinks, but they aren't forthcoming with their own requirements.

Yes, thankfully we can switch insurance companies in January, and we will definitely do that.

sweetsurrender9 · June 2014

Our insurance required us to try for a year. Then they required six cycles of Clomid before they would determine IUI or IVF to be medically necessary.

I sent them 90 pages of medical records and was able to bypass all of that because of my tubal issues. It took some digging to find out that an appeal was an option, though.

FX that you'll be able to get them to come to their senses. You might be able to appeal and get your RE to do a peer to peer review to explain to them his rationale for further intervention.

BunnyBerry · June 2014

Oh scary...it's such a messed up system. The same people who have to pay out are the ones who choose whether or not they have to pay out? Only thing I could suggest is something I saw on 3T before, to hire an insurance lawyer or advocate to appeal their decisions if needed. So sorry! Hope that by January you're looking at the best family plan though.

Lillovebug79 · June 2014

My insurance states pretty clearly what they cover. I had to do 6 medicated IUI cycles before they would approve IVF. Also, no IF treatments count toward my out of pocket max so you are lucky to have that. My policy also only covers if at 50% with a lifetime max of 12,500. Because my prescription insurance is different, it only covers 30% of fertility drugs. I would definitely ask for specifics (not sure if your state mandates a total max).

lebradford · June 2014

packerfan4life said:

LindseyM2012 said:

https://insurance.illinois.gov/HealthInsurance/infertility.asp

Check out this link. I am also from Illinois so I am looking into my insurance coverage of IF treatments too! It scares me how expensive it may be. This site says IL insurances need to cover IVF and other treatments. According to this,

"Any woman who receives coverage under a fully-insured group policy of accident
and health insurance or HMO contract for a group larger than 25 who:
1) Is unable to conceive after one year of unprotected sexual intercourse;
2) Is unable to sustain a successful pregnancy;
3) Has been diagnosed by a physician as having a medical condition that renders
conception impossible through unprotected sexual intercourse; or
4) Has undergone one year of medically based and supervised methods of
conception, including artificial insemination, which a physician has determined
to have failed and are not likely to lead to a successful pregnancy.

NOTE: Each of these four categories of infertility is
independent of the other. For example, if a physician determines that one year
of artificial insemination has failed and is not likely to lead to a successful
pregnancy a woman shall be considered infertile for purposes of this coverage,
regardless of whether she satisfies any of the other three categories of
infertility."

Which also means that your insurance company is not complying anyway because you definitely meet #3.

((Hugs)) @lebradford - I'm sorry your insurance company is being so evasive and sucky. I don't have much help to offer, my insurance company says that it will not pay for anything related to IF treatment.

_________________
Thanks, @packerfan4life. Yeah, that bolded part is written in our policy. The denial letters say it's not completely "impossible" for me to conceive (with the word impossible in quotation marks and everything). My doctor said it was very unlikely that I could conceive on my own, but that it was pretty much impossible to prove that something is 100% impossible, you know? We've exhausted all of our appeals with them and are in the process of filing a complaint with the insurance board.

I feel bad complaining because I think IL literally has the best IF coverage in the country. If our company is so hard to work with though, that pretty much makes our "coverage" useless.

There are a lot of other not-completely-IF-related issues I have with them too. They still haven't processed our other claims from February! The doctor's office says they aren't responding at all to the submitted claims, and they've told us that a few times. Also, all of our Clomid + IUI denial letters say that they are denying Clomid + IVF. I had to explain that we weren't asking to do IVF now, and they said it was pretty much the same thing, and it was still denied. ::headdesk::

Whew! Thanks for listening to my rant! I think I needed to get that out there to someone who understands that IUI and IVF are significantly different. :-P

KT416 · June 2014

I am definitely not an insurance expert, and still am not 100% clear what my own benefits are some days....

but I will say that I also live in a mandate state where my ins has to cover it. Our clinic has been really great at finding out our coverage for us and getting us approved.

In order to do IVF (we are ineligible for IUI's), my RE had to submit for approval. The approval basically is from your RE saying that it is medically necessary to have the procedure and you've tried different angles first. I would talk to your clinic and see if they have any insight for you.

lebradford · June 2014

Thanks, @KT416‌ They were helping us for a while, but they were so baffled and frustrated about all of the denials based on the 1-year issue. I think you're right though, it's time to turn it back to the clinic and get their help with some pre-approvals.

I want to know what we have to do before going to IVF, and at the same time I want a pre-approval for IUI with injects in September. I just don't know if they'll process more than one hypothetical pre-approval at a time, if that makes sense. That's one of the questions I was hoping the insurance company could answer....

bris3jbt · June 2014

I live in IL and have BCBS (individual policy, not with my company). All plans under Blue Cross Blue Shield of IL cover IVF. I didn't have to submit anything to prove I needed it or they didn't make me try a different approach before IVF. I had to pay my OOP first (about $3000) and about $800 in medicine but that was all. I can do IVF 4 times in my life with BCBS, unless I get a live birth then I can get an additional 2 more IVF's. So, a total of 6 possibly. The insurance isn't really any more expensive then I was paying Humana a month with no infertility covered. This insurance has really been wonderful. I also got the BCBS representative to email me proof of what she said on the phone and my doctor's office called to verify as well.

lebradford · June 2014

@bris3jbt‌ Thanks!! That's the kind of information I was hoping for! Well, I guess if all else fails, we will switch back to BCBS in January. That makes me feel better (though it confirms that our insurance company sucks). Thanks again!

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