Many people think if they are denied insurance coverage for fertility treatment, or simply lack benefits, their only options are bad and worse. The reality is, infertility patients are more powerful than they realize. There are numerous options people can pursue and resources they can access.
The three most important things you need to know to gain insurance benefits are:
• Consider all options available to access insurance benefits to treat infertility,
• Strategize… Determine what works best for you and become prepared, and
• Learn how to optimize communication with employers and insurance companies.
You can gain access to infertility insurance benefits through your insurer in a few different ways. If you have been denied benefits, you can file an appeal with the insurer. If you lose your appeal, you can request an external appeal through the state. With an external appeal, a medical professional that is not associated with your insurance company, will review everything. If you lack infertility benefits entirely, you can request a predetermination of benefits from the insurer. Basically, you say you know you do not have benefits, but you would like them to make an exception in your case and you explain why. Finally, if you believe the insurer has made an error or their denial was based on reasoning that goes against the state’s insurance regulations, you can file a complaint against the insurance company.
You can also access insurance benefits through your employer. This is especially successful with self-insured employers. Your human relations team can help you understand why they don’t offer benefits and you can share specific information with them to help them realize why offering IVF insurance coverage is in their best interest. Some employers do not realized they could ask the insurance agent (broker) for an additional policy option that covers infertility treatment, including IVF and prescriptions. With knowledge of options available to them, some employers may be willing to write a letter to your insurer on your behalf, pay for your care themselves, or change benefits offered to all their employees.
One example to consider is with self-insured employers. This means your company covers most of your medical expenses. At first, they may be concerned about covering the high cost of infertility treatment. However, you can educate them that the price of not providing benefits is greater. Reimbursement for In Vitro Fertilization (IVF) could cost them approximately $10,000. However, less than 3% of patients require IVF. In addition, when you share research showing people who need IVF and are without benefits, tend to transfer more embryos, which increases the chance of high-risk pregnancies, premature births, and Neonatal Intensive Care Unit expenses, which can exceed $100,000, they will pay attention to your needs. You can even share examples of self-insured companies that choose to offer insurance benefits to treat infertility, including IVF.
Strategizing which option to pursue is critical. You may not have a strong relationship with your HR department or you may be good at writing letters. Most importantly, reflect on your strengths, choose an option that works best for you and prepare for it.
Communication comes easier to some than others. Optimizing communication with insurers and employers to gain insurance benefits can be even more challenging. Insurers want factual cost information. They need to know that you are a good investment. They want to know, from your treatment, you will have more than a 5% chance of live birth. Most of all, the need to see the research to support what you are saying. Employers need to understand how providing benefits would impact them and their employees. They want answers to questions such as: How does it affect premiums? Will their employee leave after they have a baby? What are other companies offering? Will infertility benefits provide a means to retain their best employees? By identifying what information the employer needs to support infertility benefits and providing it through resources, you optimize your chance of gaining benefits for infertility treatment.
Proven techniques and resources, based on research, are available to you. Fertility Within Reach created a tool called, “The Policymaker’s Guide to Infertility Health Benefits”. It’s yours to use. We also have step-by-step instructions on how to communicate and what you need to support your conversations on our website.
Fertility Within Reach wants you to know you are not alone. Infertility and finding a way to pay for treatments can feel overwhelming, but if you take it step-by-step and utilize the support available, you will soon become an empowered patient, well on your way to securing the treatment you need to build your family.
About Davina Fankhauser
Davina Fankhauser, the foremost expert on policy related to benefits for fertility treatment and preservation, advices patients and professionals how to effectively communicate with insurers, employers, and legislators to increase access to health benefits. Davina and Fertility Within Reach’s, research based, information are sought after at both patient and professional conferences.
For more information, please visit the Fertility Within Reach website.