Health Insurance Coverage Of Infertility Treatment
Health insurance guarantees that you will not have to bear the entire burden of your health care expenses. To get this coverage, you or your employer pay a fixed premium each year to the insurer, who then provides the coverage that pays for various medical expenses.
Every insurance policy is different (some policies from the same insurer may even differ from employer to employer). It is important to thoroughly understand your particular plan, paying specific attention to covered benefits, exclusions and restrictions.
Most people are covered by group insurance policies which are designed to keep the cost of premiums lower by spreading the risk 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. It is best to obtain coverage as part of a group.
Insurance is either public or private. Public insurance includes: Medicare for elderly and disabled people, Medicaid for the needy, Veterans Administration for those who have served in the armed forces and CHAMPUS for military families. Private insurance falls into one of the following categories: 1) Commercial Insurance Companies such as Aetna, Prudential and others; 2) Non-Profit Insurance Companies such as Blue Cross/Blue Shield; 3) Self-Insuring Groups such as employers who pay benefits directly rather than using an outside insurance carrier (although a carrier may manage benefits for them); and 4) Managed Care Groups such as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).
These distinctions become particularly important when determining whether or not a state insurance law applies to your insurance plan. 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.
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.
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).
Note: This information has been excerpted from RESOLVE's Infertility Insurance Advisor, available from the RESOLVE National Office.
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