When going through Infertility procedures, its not the injections, countless trips to the clinic for bloodwork & ultrasounds or the lovely side effects to the hormones that is the major headache…it’s dealing with insurance companies!!! Especially when you are a lesbian couple! As an HR professional with over 10 years of experience, I have expertise in working with insurance companies, developing plan designs and understanding the confusing jargon but even I want to pull my hair out when it comes to dealing with insurance companies!
First let me tell you that it’s all a game and you have to know how to play! Get it in your mind that you have to be knowledgeable about your own benefit plan and what is covered. You also have to be extremely persistent to get what you want…or should I say what you pay for. Don’t let them bully you. Insurance companies purposely do three things:
1. They make policy wording so confusing that most people (including me sometimes) do not understand it. If you don’t understand the coverage, they can charge you whatever they want and you have no basis to fight them! If you do not understand your policy, I’m here to help! Please write a post or email me at firstname.lastname@example.org and I will totally assist you.
2. Make things difficult! Insurance companies are now making you get pre-authorized for everything…especially for infertility coverage. They do this on purpose to make you frustrated. A lot of people will just give up on trying get authorized for procedures because it is a constant battle that they don’t want to fight. Insurance companies are banking on this! You HAVE to be persistent and it may take daily calls to the insurance company, being patient when you are on hold for hours, speaking to supervisors, etc. Do not take “no” for an answer because you can always file grievances, even if they decline your coverage! I suggest that you check with your employer and see if they participate in any kind of health advocate program that is a separate entity from the insurance company. Health advocate programs are great in that they are an unbiased 3rd party who are trained in dealing with insurance companies. They can fight on your behalf and they are a great resource!
3. They flat out lie! Ever notice that every time you speak to an insurance rep, they can give you entirely different information? That happens all the time. In my recent battle with Aetna, I had one rep telling me one thing and literally a few hours later, a different rep will tell me something totally different and when you say, “that’s not what the other rep said earlier”, they tell you they have no reference of your earlier call and have no idea what you are talking about. They tell you when you call that they are taping the call for “quality assurance” but when you ask them to pull the tape, they can’t. DAMN LIARS! Do yourself a favor…every time you call the insurance company and speak to a rep, make a note of the date and time you called, the first and last name of the person you spoke with, a detailed description of what was told to you and ask them for a reference number. Some insurance companies will tell you that they do not provide reference numbers. In this case, you should instruct them to make a note of your call and what was discussed but you still have to take your own notes. Also, the rep may tell you that they won’t provide their first and last name but you should at least get their first name and last initial.
Pre-authorizations for infertility coverage can be very difficult, especially in the case of lesbians. Let me tell you about my recent experience with Aetna. When I first called Aetna about my infertility coverage, they told me that I had coverage for 4 cycles of in-vitro fertilization at 80% including all monitoring. I would also get an additional 2 cycles of in-vitro if there is a live birth. SWEET! I was so elated because most insurance companies do not cover infertility services and if they do, it is usually artificial insemination (IUI) which I didn’t want to do. IUI is great for some folks but if I have to go through all of the injections and stuff anyway, I would rather go with a procedure that is WAY more effective…especially if it is covered by my insurance. Then I found out that I had to get pre-authorized! Here comes the fight…
Aetna, like other insurance companies, have an infertility hotline, where you have to register. This process takes about a month so make sure you handle this before you plan to move forward with the treatment. During the registration process, I spoke with an Aetna nurse who asks you so many personal questions about your prior infertility treatments and even about your sex life. Man…do I hate putting my personal business in the street but you have no choice. It is completely legal for them to ask you these questions. I personally did not start dating women until college so I was sexually active with men from the age of 16 till about 22. I had to disclose all of my mistakes about all the men I had unprotected sex with and never got pregnant. Don’t worry…there weren’t THAT many lol…but it was embarrassing. I had to provide every detail about each infertility treatment I had and all of the details about my prior pregnancy that did not result in a birth. By the end of the call, that Aetna nurse had me in tears! She said that in order for me to be approved for infertility coverage, I had to prove that I was “clinically infertile.” Every insurance company has different meanings on what being “clinically infertile” is but Aetna stated that I had to have had 6 sperm to egg contacts with no live birth and they do not include any of those unprotected sex times during my “straight days”. They required my doctor to send them all of the information for my 2 IUI’s, 1 IVF, and 1 frozen embryo transfer. That’s 4 sperm to egg contacts…I need two more!!! There was a period that my wife and I decided to do some home insemination and I asked if that counted. She told me that the doctor would have to write up something stating that he/she monitored me during my home insemination. Also, if you used sperm from a cryobank, you had to send them receipts from the cryobank and if it was a known donor, that donor would had to have had a semen analysis done and you have to send them the results. We used a known donor for those 3 or 4 home insemination cycles but we never had him get a semen analysis. This is where an AWESOME doctor that had my back came in! I don’t want to get anyone in trouble but let me just say that having an understanding with your doctor can really come in handy and my doctor was able to assist me in getting the coverage I needed!
I cannot say enough about persistence because after both myself and my clinic sent Aetna all the documents they required, no one from Aetna followed up. I would call them every morning and say “am I approved?” They would tell me we are waiting for some additional information and since I’m an HR person and NOT a mind reader, how the hell would I know they are waiting on something if they don’t call and tell me! See…that’s the kind of sh*t they pull. It seemed like this was the case every day and I basically started every conversation with “I’m calling today to find out what else you need to approve my coverage since you can’t call me and let me know what you need!” After almost a month of going back and forth, they tell me I was approved!
At that point, I’m thinking that I’m so happy I don’t have to deal with this insurance fight anymore but that was not the case. The next fight is the pre-authorization for the injectable medications!!! My question is this…If they have a team of nurses who approve you for IVF, they should know that you have to take certain medications with that process so why do I have to go through another pre-authorization for meds? It’s so stupid but like I stated earlier, insurance companies try their best to make things difficult on purpose! My doctor prescribed a Lupron kit, Follistim, Ovidrel, Progesterone and antibiotics that they want you to take after the egg retrieval. To control their costs, Aetna (as well as many other insurance companies) requires infertility meds to be filled through their mail order pharmacy so my doctor had to fax over all the prescriptions. Now I’m being persistent with Aetna specialty pharmacy and calling them daily for updates. In my many calls to them, I find out that Follistim is not one of their “preferred drugs” aka…they don’t want to pay for it because it’s more expensive! They required that the doctor fax over a new prescription for Gonal F which is very similar to Follistim (and cheaper). I once again had to explain to the rep that I don’t have psychic abilities so how would I have known that I needed a new prescription if they didn’t call me. Of course she didn’t have an answer for that! It also pissed me off that I’ve taken Follistim during 3 separate cycles and my body reacted well to it. Why do insurance companies get to tell you what you have to take and not your doctor? Well they can and they do! So then I was going back and forth with the doctor to fax over a new prescription. I got another feeling that something else would go wrong so I kept calling the pharmacy daily. I guess I do have some psychic abilities because when I called again, they told me that Ovidrel is a controlled substance and they will not ship it to NY. Ok…so now Aetna is requiring me to use their mail order pharmacy but they won’t ship it to me. Does that make sense? What did I say earlier about them making things difficult??? Now I had to fight to get authorization to take that script to my local pharmacy since they wouldn’t ship it! OMG! If you do not listen to anything that I advise, please listen to this! DO NOT START YOUR CYCLE WITHOUT HAVING ALL OF YOU MEDS IN YOUR POSSESION! God forbid, you start a cycle and then have problems with the insurance company to get the rest of your meds, then you either have to 100% pay out of pocket or stop your cycle! Just so you know, drugs like Follistim and Gonal F are about $1200 – $1500 per vial so you don’t want to pay out of pocket if you don’t have to!
If you do not have coverage for the medications, my advice is to call around to every pharmacy in your area. Each pharmacy has different costs in terms of medications and difference in price for infertility meds can be astounding!. For example, during one of my prior procedures, Lupron was not covered. I called one pharmacy and they wanted $675.00 per kit…another pharmacy wanted $125.00. It’s the exact same medication so guess which one I chose!
One of the last things I want to mention is flexible spending plans (FSA) or some places call it health care reimbursement (HCR). Even if you have infertility coverage, there are going to be some costs that you have to pay for like copays for visits & meds and your percentage of the procedure costs. It’s rare that plans will cover infertility at 100%. If your employer has a flexible spending plan, it is important that you participate. FSA plans deduct money from your paycheck on a pre-tax basis and allow you to use those funds for medical expenses. Infertility costs are definitely covered by all FSA plans. You can choose to put as much money into that plan as you want but there is a maximum of $2500.00 per year. You usually have to sign up during your open enrollment period (usually at the end of the year) for the deductions to start the next year. The great thing about the plan is that most of these plans put the money on a “benny card” which is card just like a credit card with a mastercard or visa logo. You also have access to all the money on January 1 even though you haven’t contributed all of the money yet. For example, last year, I chose to put the max ($2500.00) in my FSA plan. Because I’m paid bi-weekly, I have a pre-tax deduction of $96.15 per paycheck for the entire year but the entire amount ($2500.00) was put on my benny card on 1/1/14. It should be noted that the rule was if you don’t use the entire amount by the end of the year (12/31) you would lose it but the IRS just changed the law to state that you can roll over up to $500.00 of any unused funds from year to year so choose your election amount wisely! One other thing to note about FSA plans, married spouses are covered under this plan so if you are married in a state where gay marriage is legal, you can use this benefit for yourself or for your married partner.
Ok…it’s time to wrap up this post and I apologize for being so wordy but insurance is a big piece to this whole process and I wanted to explain it in detail! Below is a listing of questions you should ask the insurance company when looking for infertility coverage:
1. Do I have infertility coverage and if so, exactly what procedures are covered?
2. Is there a pre-authorization for infertility coverage and if so, what does that entail?
3. Does this coverage include monitoring (blood work, ultra sounds, diagnostic testing, etc)?
4. At what percentage are my procedures covered? (For example, Aetna covers my IVF at 80% and I am responsible for the other 20%)
5. Are the medications covered as well and if so can I go anywhere to get them filled or do I have to go through the insurance companies’ mail order pharmacy?
6. What are my copays? (Note: there may be different copays for office visits, diagnostic testing, and monitoring so take note of what each copay would be)
7. Do I have an out-of-pocket maximum and if so, once I reach that, am I covered at 100%? (Most plan designs have an out of pocket maximum which means that you do not have to pay anything over a certain amount. My plan has a $1250.00 out of pocket maximum so when I hit that amount, everything else would be covered at 100%. And that’s everything…not just infertility. Once I hit that $1250, I can go to any in-network doctor, fill any medication or get any test done at no additional cost to me!) Make sure you keep tabs and get receipts for everything you spent out of pocket because no one will let you know when you hit that out of pocket maximum.
8. Get a list of infertility doctors that are in-network. You want to use someone that the insurance company has as in-network in order to get the most coverage. I suggest that you call around to those in-network doctors and find out what they charge the insurance companies because the more they charge the insurance, the more you will have to pay with your percentage!
Ok…that’s it but I may add some additional information as it comes to me but I’m sure I overloaded you already. Once again, if you need assistance and want to be a bit more private, please feel free to email me at email@example.com.
Thank you!. 😉