Understanding your health insurance


Don't take NO for an answer!

There are no real standards for infertility coverage and every policy seems to read a little differently. The people writing these policies don't have, in many cases, the understanding of infertility that you do. While certain areas under the auspices of infertility are covered --- others are not. Because this is such a gray area, don't take a denial as the final word.

Don't take NO for an answer!

Many times when you call your insurance company for a referral or for permission to see a particular physician, you will be speaking to a customer service person who knows far less about what is covered or even what is being asked than you do.

Much of what is or is not covered would seem many times to lack the most basic logic. Infertility is one of the few areas where many times diagnosis is covered but not treatment! Insurance coverage varies drastically not only by plan but also by employer.

It is as important to look at the what is written in your policy as to look at what is NOT written. Many times if the procedure is NOT EXCLUDED... it will be covered. You are the person who needs to look critically at your policy and decide what is covered. Do not leave this task to other people because YOU need to be your own best advocate. No one in human resources is going to have the vested interest that you do.

Review your insurance contract. Your contract guarantees you (the insured) the right to have certain types of care and procedures and all the covered components surrounding said procedures. Question, read and reread the contract until you are sure there is a complete understanding of what exactly is included and/or excluded in your contract. Do NOT stop until you are completely satisfied with the answers you receive.

Group Insurance

Understanding Insurance Coverage

Most Americans get health insurance through their jobs or are covered because a family member has insurance at work. This is called group insurance. Group insurance is generally the least expensive kind. In many cases, the employer pays part or all of the cost.

Some employers offer only one health insurance plan. Some offer a choice of plans: a fee-for-service plan, a health maintenance organization (HMO), or a preferred provider organization (PPO), for example. Explanations of fee-for-service plans, HMOs, and PPOs are provided in the section called Types of Insurance.

Group Insurance

Group insurance is generally the least expensive kind. In many cases, the employer pays part or all of the cost. Some employers offer only one health insurance plan. Some offer a choice of plans:

Fee-for-service plan,

A health maintenance organization (HMO),

Preferred provider organization (PPO), for example.

Explanations of fee-for-service plans, HMOs, and PPOs are provided in the section called Types of Insurance.

What happens if you or your family member leaves the job?
You will lose your employer-supported group coverage. It may be possible to keep the same policy, but you will have to pay for it yourself.

This will certainly cost you more than group coverage for the same, or less, protection. A Federal law makes it possible for most people to continue their group health coverage for a period of time. Called COBRA (for the Consolidated Omnibus Budget Reconciliation Act of 1985), the law requires that if you work for a business of 20 or more employees and leave your job or are laid off, you can continue to get health coverage for at least 18 months.

You will be charged a higher premium than when you were working. You also will be able to get insurance under COBRA if your spouse was covered but now you are widowed or divorced. If you were covered under your parents' group plan while you were in school, you also can continue in the plan for up to 18 months under COBRA until you find a job that offers you your own health insurance.

Not all employers offer health insurance. You might find this to be the case with your job, especially if you work for a small business or work part-time. If your employer does not offer health insurance, you might be able to get group insurance through membership in a labor union, professional association, club, or other organization.
Many organizations offer health insurance plans to members.

Individual Insurance

Individual Insurance

If your employer does not offer group insurance, or if the insurance offered is very limited, you can buy an individual policy.

Insurance is provided through two major sources:

Public -- Medicare for the elderly, Medicaid for the disabled or needy, Veteran's Administration for those who have served in the Armed Forces, and Champus for Military Families or

  • Private --- Includes insurance provided for by private companies

          

    • Commercial Insurance Companies
    • Nonprofit Insurance Companies and
    • Self-insured Groups (employers who pay benefits directly rather than using an insurance carrier).

You can get a Fee-for-service plan, HMO, or PPO protection. But you should compare your options and shop carefully because coverage and costs vary from company to company.

Individual plans may not offer benefits as broad as those in group plans. If you get a noncancellable policy (also called a guaranteed renewable policy), then you will receive individual insurance under that policy as long as you keep paying the monthly premium.

The insurance company can raise the cost, but cannot cancel your coverage. Many companies now offer a conditionally renewable policy. This means that the insurance company can cancel all policies like yours, not just yours.

This protects you from being singled out. But it doesn't protect you from losing coverage. Before you buy any health insurance policy, make sure you know what it will pay for...and what it won't.

To find out about individual health insurance plans, you can call insurance companies, HMOs, and PPOs in your community, or speak to the agent who handles your car or house insurance.

Tips when shopping for individual insurance:

  • Shop carefully. Policies differ widely in coverage and cost.
  • Contact different insurance companies, or ask your agent to show you policies from several insurers so you can compare them.
  • Make sure the policy protects you from large medical costs.
  • Read and understand the policy.
  • Make sure it provides the kind of coverage that's right for you. You don't want unpleasant surprises when you're sick or in the hospital.
  • Check to see that the policy states: the date that the policy will begin paying (some have a waiting period before coverage begins), and what is covered or excluded from coverage.
  • Make sure there is a "free look" clause. Most companies give you at least 10 days to look over your policy after you receive it. If you decide it is not for you, you can return it and have your premium refunded.
  • Beware of single disease insurance policies. There are some polices that offer protection for only one disease, such as cancer. If you already have health insurance, your regular plan probably already provides all the coverage you need.
  • Check to see what protection you have before buying any more insurance.

Investigating your policy

Investigating your Policy

One way to keep costs down is to EXCLUDE coverage for illnesses that insurers believe are non-life-threatening.

Infertility is seen by many companies to be "elective" and nonlife-threatening.

When examining a claim, insurance companies look at WHAT is procedure is being claimed and the WHY it is being performed. The WHAT and the WHY is the basis of a claim's acceptance or denial.

The WHAT

CPT Codes: ( Physicians Current Procedural Terminology) A listing (and coding) of procedures and services performed by the physician. These codes are systematic standarized and put forth by the American Medical Society.

The WHY

ICD-9 Codes: These codes give the insurance company the diagnosis from the doctor of your condition.
This gives the insurance company the information about why you are being treated: endometriosis, PID, Blocked Tubes etc.

If insurance companies do not agree with the WHAT (CPT codes) or the WHY (ICD-9) they may deny the claim. Many carriers may cover the cost to diagnose but not to treat.

Knowing how the codes are applied to your insurance may help you not only get something covered but also be sure codes are being properly applied for more efficient payment of the physician or for reimbursement for you.

Get Copies of Your Documents

It is as important to get copies of your own records as it is to see a copy of your insurance contract.

Call you physician's office and get copies of all your labs, notes etc. Then call your (or your spouses) benefits office for contract information. If you are insured individually, call your agent.

The policy comes in two forms, a contract (which is usually not provided to you in a group policy, unless you ask, or a summary plan booklet. The booklet is a brief summary of the benefits.

Read your Documents

Even your booklet is a "contract" written specifically to spell out not only what IS covered but to exclude what is not covered. Disputes over the policy language have traditionally sided with the insured.

Insurance companies are designed to cover the insured in the event they suffer from an "illness" or "injury".

ADA - Recognizes Infertility

In 1990 The American Fertility Society, now the ASRM (American Society for Reproductive Medicine), defined infertility as a disease. then in 1996, Pacourek v. Inland Steel Co., 64 U.S.L.W. 2550 (N.D. Ill. Feb. 16, 1996) reasoned that including the reproductive system in the regulation's list of body systems which can be impaired for purposes of the ADA would have been superflous had the EEOC rulemakers, and Congress before them, not intended infertility to be a disability covered by the Act. The court also found that a major life activity should be characterized in terms of the quality of life, not merely the frequency of the activity

There are numerous physical problems that accompany infertility as a disease process, endometriosis, polycystic ovarian syndrome etc. Being defined as a "disease or illness" may be a step in the direction of coverage instead of exclusion.

Exculsions

Review carefully this portion of your insurance booklet or contract. Pay careful attention to the terms and definition of the terms and language of the contract.

If a procedure is no specifically listed in the exclusions area of your policy, it would be fair to assume the procedure is covered and this opens the door to an appeal for a denial of coverage.

Denials

In the past, insurance carriers that have denied claims for one of the following four reasons:

1. Infertility is not an illness;

2. Treatment of infertility is not medically necessary;

3. Treatment of infertility is experimental.

4. Excluded Treatment

 

Not Medically Necessary

Traditionally, having a baby is not looked upon as being medically necessary. Most insurers, however, will pay for treatment where an illness or disease contributes to infertility IF treatment is not just for the purpose of getting pregnant.

Because of this, portions of infertility treatments can be broken out and paid for using specific billing codes. Review of the "denied claim" as not medically necessary can often be resubmitted successfully with additional information from the physician.

An Experimental Procedure

In the past IVF seemed to fall under this catagory. Today denying coverage as "experimental" is simply not a valid reason.

Excluded Procedure

You should examine this area very carefully. Most medical procedures have many different components. There may be sub-areas within the procedure that are not excluded and there fore portions of the procedure might be copied.

Look carefully at the language. IVF may not be a covered procedure but when broken down into the billing codes for egg retrieval, embryo transfer, blood work etc, a number of the services might be covered. IVF and embryo transfer might be excluded but with no mention of GIFT (Gamet Intrafallopian Transfer) which could open the door for coverage for this specific procedure.

 


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