Even in states with mandated coverage, some people do not have benefits for infertility treatment under the insurance plan purchased by their employer group. If an employer chooses to “self fund” the insurance plan, the employer can choose to provide coverage for infertility in full, to set a life time maximum on infertility benefits by dollar or by number of attempts, or not to provide coverage at all. The employer has this right because the employer group – not the insurance company – pays all claims. The insurance company acts as a review board for the employer only, and the employer in turn takes the risk of the potential for high claim rates.

The first step in exploring your infertility benefits is to call the “Member Services” phone number on your insurance card.  It’s better to call than rely on the manual provided by your company’s human resources department, which may not have the most recent information available.

When calling, give the insurance representative your name, insurance identification number, group number if applicable, and date of birth for verification.  We suggest asking the following questions to verify your coverage:

1 – Is infertility a covered benefit on this plan?       

If the answer is no, ask if the plan is “self funded”.  If the answer is “no” and you are a Massachusetts resident, you should have coverage, and you should discuss coverage further with your company’s human resources department.

2 – Does this plan provide coverage for intrauterine insemination (IUI), in vitro fertilization (IVF) and embyro cryopreservation?

3 – Are medications covered by this plan? If not, how are infertility medications covered?

4 – Is there a lifetime maximum for benefits?

If the answer is yes, ask what the maximum is, and whether medications count toward the maximum.

5 – Is prior authorization required for infertility services?

Submitting for prior authorization

Many insurance providers require infertility services to be authorized prior to the start of a treatment cycle. Insurance companies use several tests and historical factors to determine medical necessity for coverage. Below is a list of several of common requirements. Please be aware these can change.

Have you been trying for one year to conceive without success?
The mandate for infertility coverage in Massachusetts defines infertility as having attempted conception for one year without success. Although success in the mind of someone trying to have a baby is usually the delivery of a healthy child, insurance companies consider even a pregnancy that ends in miscarriage as success; consequently, your insurer may require you to attempt to conceive for a year from the date of the miscarriage. During the past year, insurers have sent RSC financial coordinators many rejections for prior authorization for treatment due to pregnancies that ended in miscarriages, saying the one-year requirement from miscarriage had not been met.

Do you ovulate regularly?
If a woman is not ovulating, insurance companies may also deny authorization, saying that if an egg is not being exposed to sperm, then conception is not being attempted. If you do not ovulate regularly, your insurance plan may cover you for ovulation induction without intrauterine insemination for a limited number of cycles.

Do you smoke?
Some Massachusetts insurance companies deny infertility coverage if the female partner smokes, not providing coverage unless the woman undergoes a smoking cessation program, followed by a urine test to detect nicotine in the body.

Have you had a tubal ligation (having your tubes tied) or a vasectomy?
Once you have had a voluntary sterilization – regardless of a reversal of the procedure – insurance companies are under no legal obligation to provide coverage for infertility services, unless there is another cause of infertility.  For example, if the male partner has had a vasectomy, but the female partner has bilateral tubal blockage, the cost of IVF would be covered since the female would be unable to conceive even if the male had not had a vasectomy.

Insurance companies often require the following testing for review:

Day 3 FSH/E2 Test – A measure of female hormone levels commonly required once a year, but may be required every six months after the age of 40.

Clomid Challenge Test – A measure of a woman’s egg supply commonly required once a year for women age 40 or older.

HSG or hysterosalpingogram – An X-ray examination of the fallopian tubes which is commonly required once every four years.

Uterine Cavity Evaluation – Required yearly.

Semen Analysis – Required yearly.  If the results are poor, insurance companies may require a second analysis or a urological consultation.

Once the above testing is complete, the insurance company receives the results on their standard form, along with results and history of your past treatment.  The insurer then compares results to its coverage criteria or may send the results on to a physician for further review.  An insurance company legally has up to 30 days to respond to a request. But many insurers typically respond within 2 weeks if no physician review is needed.

Insurers typically grant authorizations for a six-month period and for from one to three cycles.  After completion of the authorized tests and/or treatment, the physician must resubmit information to the patient’s insurance company, which may require that some testing be repeated. 

Insurance Denials

When an insurance company denies a claim, the patient has a right to appeal the decision by submitting a request in writing with supporting documentation, usually in the form of a letter, from the treating physician.  Legally, an insurer must review an appeal within 30 days of receipt; the insurer may also send information to a consulting reproductive endocrinologist for review.  The insurance company considers this a “first level” appeal and may or may not reverse its denial.

If the insurance company upholds its denial, it will inform its customer of the remaining options for further review of the case.  After all options are exhausted within the internal appeal system, the patient has the option of filing a request with the state Department of Patient Protection or the Department of Healthcare Advocacy for an external review.  You can reach the Department of Patient Protection or Department of Healthcare Advocacy through your local Division of Insurance.  A managed care ombudsman can then help you file an appeal or grievance.

The Department of Patient Protection can only assist you if infertility is a covered benefit under your plan and after you have exhausted all appeal options within your insurance company.