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Health Insurance 101

The Basics
Types of Plans - Public Insurance and Private Insurance
Laws and Mandates - ERISA, State Laws, Mandate to Cover, Mandate to Offer
What You Can Do

Health insurance guarantees that an individual will not have to bear the entire burden of his/her health care expenses. But in the case of infertility, the majority of patients bear the responsibility of covering the costs of treatment. Depending on the cause of the fertility problem and the therapy used to treat the problem, that cost can be considerable.

No one expects to receive the diagnosis of infertility. Yet more than 7 million Americans are subject to that diagnosis. No one expects that their insurance company will deny them coverage for this medical condition. But most do. A major impediment to access to treatment to resolve infertility is insurance coverage.

Insurance Coverage - The Basics
Your health insurance policy is an agreement between you and your insurance company. To get this coverage, you or your employer pay or share the cost of a fixed premium each year to an insurer (such as Blue Cross and Blue Shield), who then provides the coverage that pays for various medical expenses.

Your policy lists a package of medical benefits such as tests, drugs and treatment services. The insurance company agrees to cover the cost of certain benefits or expenses listed in your policy. These are called “covered services.”  Your policy also lists the kinds of services that are not covered by your insurance company. You have to pay for any uncovered medical care that you receive.

Keep in mind that a medical necessity such as an infertility treatment, is not the same as a medical benefit. A medical necessity is something that your doctor has decided is necessary. A medical benefit is something that your insurance plan has agreed to cover. In some cases, your doctor might decide that you need medical care that is not covered by your insurance policy.

Insurance companies determine what tests, drugs and services they will cover. These choices are based on their understanding of the kinds of medical care that most patients need. Your insurance company’s choices may mean that the test, drug or service you need isn’t covered by your policy.

Insurance policies vary widely and may even differ from employer to employer from the same insurer. It is important to thoroughly review and seek clarification about the provisions of a particular plan, paying specific attention to covered benefits, exclusions and restrictions as they relate to reproductive health services and infertility diagnosis and treatment.  In order to get accurate information, your health plan administrator should provide you with a copy of your plan’s Summary Plan Description (SPD). It outlines your benefits, covered services and your legal rights under the Employee Retirement Income Security Act (ERISA), the federal law that protects your health benefits. It should contain information about the coverage of dependents, what services are included and will require a co-payment, the rules for pre-existing conditions, and the circumstances under which your employer can change or terminate a health benefits plan.

Types of Health Insurance Plans
Most people are covered by group insurance policies, which are designed to keep the cost of premiums lower by spreading the expense risks among all the members in the group. Some people do not have access to a group plan and thus purchase individual insurance policies for themselves and their families. However, it is often difficult and very expensive to purchase individual insurance policies. Therefore, it is best to obtain coverage as part of a group if possible.

Insurance is either public or private.

Public insurance includes governmental programs such as: Medicare for the elderly and disabled, Medicaid for the poor, the Veterans Administration for those who have served in the armed forces and TriCare for current military personnel and their families.

Private insurance falls into one of the following categories:

  1. Commercial Insurance Companies such as Aetna, Cigna, United and others;
  2. Non-Profit Insurance Companies such as the numerous Blue Cross/Blue Shield plans across the country;
  3. Self-Insuring Groups such as employers who pay benefit claims directly rather than using an outside insurance carrier (which might be hired to serve as the benefits manager).  

Insurers are applying managed care techniques to promote lower cost, high quality care whenever possible and typically offer plans with varied levels of controls ranging from tighter, in-network provider choices in Health Maintenance Organizations (HMOs) to hybrid approaches called Point of Service (POS) plans, to more costly and greater individual choice options known  as Preferred Provider Organizations (PPOs).

The Laws and Mandates
The above distinctions become particularly important when determining whether or not a state insurance law applies to your insurance plan.

ERISA. For example, pursuant to the Federal Employee Retirement Income Security Act (ERISA), self-insuring businesses are not required to comply with state insurance mandates, although they may voluntarily provide these mandated benefits.  Therefore, a state law requiring insurance companies to cover infertility cannot apply to companies that “self-insure,” that is, which do not purchase insurance policies but instead pay medical claims themselves.  This is because ERISA  prevents states from being able to regulate self-insured companies.  However, if drafted correctly, a federal law requiring insurance for diagnosis and treatment of infertility could overcome ERISA and could require all, or at least more, employers to provide infertility insurance.

Unlike typical pregnancy-related services guaranteed nationally as basic health plan benefits under the National Pregnancy Discrimination Act, infertility treatment services are not similarly ensured.  Coverage, particularly for assisted reproductive technologies, is extremely limited.  In the United States, only one in five employers provide infertility treatment benefits to their employees and these policies vary widely in their comprehensiveness, reimbursement limits, and eligibility requirements.

Although no federal law requires insurance coverage for infertility treatment, 15 states have enacted some type of infertility insurance coverage law. Each law is different, but most can be generally described as either a mandate to cover or a mandate to offer. Follow this link for complete list of state laws.

Mandate to Cover: is a law requiring that health insurance companies provide coverage of infertility treatment as a benefit included in every policy (policy premium includes cost of infertility treatment coverage).

Mandate to Offer: is a law requiring that health insurance companies make available for purchase a policy which offers coverage of infertility treatment (but the law does not require employers to pay for the infertility treatment coverage).

What You Can Do
More and more women and men in their most active and productive years are being afflicted by the physical and emotional hardships of a treatable disease that continues to be inappropriately viewed as “elective.”  If you are infertile and your employer does not currently provide infertility treatment coverage, make a formal request for them to do so.  Get the support of others covered by the plan who are experiencing similar infertility problems.  RESOLVE encourages you to become your own best advocate for expanded health benefits.  The evidence justifying the cost-benefit of such coverage is considerable.