The International Council on Infertility Information Dissemination, Inc

The impact of Bragdon v. Abbot on persons affected by infertility by Pamela J Walker

Americans with Disabilities Act

 

In order to have an understanding of the impact of Bragdon v. Abbott on persons affected with infertility, it is first necessary to give a brief overview of the Americans with Disabilities Act (ADA).

 

The ADA was enacted in 1991. Title I of the ADA protects all persons with disabilities and prohibits an employer from discriminating against them in any terms or conditions of employment. Fringe benefits or health insurance plans are a term or condition of employment. Title III of the ADA prohibits any place of public accommodation from discriminating based on disability in its goods, services, facilities, privileges, advantages or accommodations. An insurance carrier is a public accommodation.

 

Most persons with insurance coverage obtain their coverage through their employment. The employer either pays an insurance company the policy premium (premium-paid policy) or is self-funded and retains an insurance company to administer the plan (ERISA). ERISA is a federal law that regulates self-funded pension and insurance plans. An ERISA plan will pre-empt any state laws regulating insurance, but not federal laws. The ADA is a federal law. The type of insurance coverage you have is important to know so that you know who is violating the law. Under a premium-paid policy both your employer and the insurance company are violating the law. Title I prohibits your employer from contracting with any other person, company, etc. that discriminates. The insurance company would be violating Title III. If it is an ERISA plan, it is a little more difficult to claim a Title III violation against the insurance company because the employer generally sets up the terms of the plan (although it is the insurance company that advises them what to do). This information is provided so that if you should decide to bring a claim under the ADA, you understand that if you have an ERISA plan, you will have to sue your employer for a good chance of recovery. You may also sue the administrator of the plan, but the law is unsettled on this issue.

 

The ADA defines a disability as a "physical or mental impairment that substantially limits one or more of the major life activities of such individual." Thus, to be protected under the ADA, a person must establish he or she has (1) a physical or mental impairment that (2) affects a major life activity.

 

A physical or mental impairment has been defined in the Code of Federal Regulations to mean:

Any physiological disorder, or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: Neurological, muscoskelital, special sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genital-urinary, hemic and lymphatic, skin, and endocrine; or … 
The Code of Federal Regulations also defines major life activities to include walking, seeing, breathing, caring for oneself, etc. Reproduction is not included in the list of major life activities in the Regulations. However, the Regulations do state the list is not exclusive but is given by way of example. Thus, there are major life activities that are not listed.

 

Since the enactment of the ADA there have been many cases where persons with infertility or HIV have sought protection under the ADA. The major issue in these cases was whether or not reproduction is a major life activity under the ADA. There was a split in the decisions. The majority of the Federal District Courts ruled that reproduction was a major life activity. Three of these rulings were appealed to the Federal Court of Appeals, Zatarain v. WDSU-Television (5th Circuit), Krauel v. Iowa Methodist Medical Center (8th Circuit) and Bragdon v. Abbott (1st Circuit). The Fifth and Eighth Circuits ruled reproduction was not a major life activity. The First Circuit ruled that it was. Obviously, the First Circuit ruling was further appealed to the United States Supreme Court.

 

Bragdon v. Abbott

Abbott was infected with the HIV virus. She did not have full blown AIDS. A person infected with HIV, who is asymptomatic, does not necessarily have any major life activities affected, other than reproduction. A person with HIV will forego intercourse and reproduction because he/she does not want to pass the virus to his/her spouse or child. Thus, the only "major life activity" affected is the ability to reproduce.

 

Abbott sought dental care from Bragdon. She informed him that she was infected with HIV. Bragdon refused to treat Abbott in his dental office, but stated he would perform the necessary procedures in a hospital setting, which would have been more costly. Abbott filed a Complaint under Title III of the ADA (public accommodations).

The major issue in the case was whether Abbott was disabled within the meaning of the ADA, i.e. is reproduction a major life activity under the ADA. The United States Supreme Court held that it was. Although Bragdon v. Abbott, was in the HIV context, the ruling also applies to persons with infertility. Thus, persons with infertility are protected under the ADA because they have a physical impairment of the reproductive system that affects their major life activity of reproduction.

 

Thus, under the ADA your employer, and, if relevant, insurance carrier, cannot discriminate against you based on your disability --- infertility. They must treat you the same as other persons. They cannot deny you leave to seek medical treatment if they provide leave for other persons. They cannot fire you for seeking medical treatment or because of your infertility if they would not do the same to others.

 

Safe Harbor
Of course, the big question is, how does this affect my health insurance that excludes or limits infertility treatments? Under the ADA there is an additional provision known as the "safe harbor" provision that affects insurance. Basically what this provision states is that the ADA is not intended to affect how insurance companies do business or how your employer sets up its health insurance coverage unless it is a "subterfuge" under the

ADA.

 

The Courts are still not in agreement as to what this provision of the ADA means. The Eighth Circuit in Krauel, held that to be a "subterfuge" the employer must discriminate in a "non-fringe benefit" aspect of your employment. For example, you have infertility and you are going to cause our insurance costs to increase so we will not hire you or fire you.

 

The Equal Employment Opportunity Commission (the federal agency in charge of enforcing discrimination laws) and other courts have interpreted this language as meaning that the employer must establish that the exclusion or limitation is based on sound actuarial principles. This means they have to establish it is too costly, the premiums will be too high, it will bankrupt the Plan, etc. History has shown that providing coverage for infertility treatments is simply not expensive, i.e., $.34 to $2.00 per family plan per month.

 

 

Summary

In summary, persons with infertility are disabled within the meaning of the ADA. However, the courts are still in a state of flux as to whether or not an employer or insurance carrier may exclude or limit treatments for infertility. The only way of getting the answer is to pursue litigation and attempt to get a case before the United States Supreme Court.

Pamela J. Walker

 

Buzzanca v. Buzzanca: The Ruling and Ramifications

Buzzanca v. Buzzanca: The Ruling and Ramifications
by Andrew W. Vorzimer, Esq.; Milena D. O'Hara, Esq.; Lori D. Shafton, Esq.

 

Jaycee was conceived by an anonymous embryo donation implanted into a gestational surrogate. The surrogate and the Buzzancas had entered into a surrogacy contract in which the surrogate agreed to carry and give birth to a child for them. However, approximately one month before Jaycee was born, John petitioned for dissolution of their marriage. Although Luanne claimed she was the lawful mother, John asserted that he was not responsible in any way towards Jaycee. Despite the fact that the surrogate appeared to disclaim any assertion that she was the legal mother, the trial court stated neither the surrogate nor Luanne was the legal mother. Further, it held that John could not be the legal father. The court's basis for these assertions was a strict, and even incorrect, reading of the Uniform Parentage Act: to be a legal parent, one must either be genetically related to the child or have given birth to the child. Following this reading, the court found that neither Luanne nor John satisfied either of these requirements.

 

California Appeals Court reverses "No Parents" decision in surrogacy case

The renowned "parentless" child resulting from a surrogacy arrangement finally knows who her legal parents are. Yesterday, the California Court of Appeal for the Fourth Appellate District ruled that John Buzzanca and Luanne Buzzanca are the legal father and mother of Jaycee, now three years old. The basis for the court's conclusion was the rule that parental relationships may be established when intended parents initiate and consent to medical procedures, even when there is no genetic relationship between them and the child. Buzzanca v. Buzzanca, Sup. Ct. No. 95D002992 (filed 3/10/98).

 

Uniform Parentage Act criteria is not exclusive

The appellate court's reasoning in reversing the trial court begins with Section 7610 of the Uniform Parentage Act. That section states: "The parent and child relationship may be established as follows: (a) Between a child and the natural mother, it may be established by proof of her having given birth to the child, or under this part; (b) Between a child and the natural father, it may be established under this part; (c) Between a child and an adoptive parent, it may be established by proof of adoption." (Emphasis added).

 

First, the court clarifies that the phrase "under this part" means through genetic consanguinity, as so held in Johnson v. Calvert. Thus, the three listed methods of establishing a relationship are through genetic ties, giving birth or through adoption. In analyzing this section, the court emphasizes the word "may" as meaning that this list of these methods to determine parentage is not exclusive, and it may in fact be determined in other ways. This is evidenced by the fact that under section 7611, a man may establish paternity by being married to the mother when she gives birth, or marrying her thereafter if he either consents to being named the father, or promises in writing to support the child. It is possible that he may not be genetically related to the child, but he may nevertheless establish paternity.

 

Parental relationships may be established when consent is given and medical procedures initiated

Having clarified that the methods in section 7610 are not exclusive, the court held that parental relationship also may be established when medical procedures are initiated and consented to by the intended parents, even when there is no genetic relationship between them and the child. The basis for this groundbreaking holding are found in section 7610, section 7613 and basic common law estoppel principles.

 

First, as already discussed, section 7610 does not provide an exclusive choice of methods to establish a parental relationship. Apparently, the court is willing to expand the list of methods to keep up with technology, despite the absence of explicitly supporting legislative history: "[C]ourts must construe statutes in factual settings not contemplated by the enacting legislature." (quoting Johnson v. Calvert, 5 Cal.4th 84, 89 (1993).

 

Second, the court relies on section 7613 of the UPA: "If, under the supervision of a licensed physician and surgeon and with the consent of her husband, a wife is inseminated artificially with semen donated by a man not her husband, the husband is treated in law as if he were the natural father of a child thereby conceived." The focal point of this section is "consent". In the case at hand, a gestational surrogate was implanted with the genetic material of unknown donors. The statute explicitly covers a woman who is implanted with the semen of one other than her husband. Despite the obvious dissimilarities, the court focuses on the intent to procreate, which is present in both situations: "Both contemplate the procreation of a child by the consent to a medical procedure of someone who intends to raise the child but who otherwise does not have any biological tie. . . . If a husband who consents to artificial insemination under section 7613 is ‘treated in law' as the father of the child by virtue of his consent, there is no reason the result should be any different in the case of a married couple who consent to in vitro fertilization by unknown donors and subsequent implantation into a woman who is, as a surrogate, willing to carry the embryo to term for them. The statute is, after all, the clearest expression of past legislative intent when the legislature did contemplate a situation where a person who caused a child to come into being had no biological relationship to the child."

 

Third, under common law estoppel principles, exemplified in the case of People v. Sorenson, the court states that "[b]y consenting to a medical procedure which results in the birth of a child – which the Sorenson court held establishes parenthood by common law estoppel – a husband incurs the legal status and responsibility of fatherhood." (citing People v. Sorenson , 68 Cal.2d. 280 , 285 (1968)). The court uses this as a basis by expanding the Sorenson decision to include establishing maternity, and by reading the case in conjunction with section 7613, which has its roots in Sorenson. Accordingly, under the second and third bases for its ruling, the court states that both parents may establish parenthood based on their consent to a medical procedure intended to bring a child of their own into the world.

 

Court establishes legal "mother" in surrogacy agreements

Further, the court is careful to point out the compelling state interest in avoiding a "parentless" child situation, not burdening taxpayers, and establishing paternity, as explicitly stated in UPA section 7570(a). The court states that theJohnson v. Calvert case clearly precludes a court from declaring the surrogate or an egg donor the legal parents of a child conceived from a surrogacy arrangement. Thus, not only is the decision to analyze maternity the same as paternity under the UPA, as explained above, logical, but it also avoids the question as to who is the legal mother of the child.

 

Accordingly, the court ruled the parental relationship between the Buzzancas and Jaycee was established by evidence that medical procedures were initiated and consented to by Buzzancas, even though neither was genetically related to Jaycee, and Luanne did not give birth to her. As the court quotes Professor Hill, a legal commentator on the subject, the intended parents are the "first cause, prime movers, of the procreative relationship."

 

Paternal responsibilities established

The court rejected John's arguments that the contract was not signed before the procedure, and that Luanne promised to assume all responsibility for Jaycee's care. First, the court briefly acknowledged the first argument, stating there was an agreement, despite that it was not in writing before the implantation. Second, the court emphasized that even if Luanne promised to assume all responsibility for Jaycee's care, he is nevertheless the father and may not avoid his financial responsibilities. It stated that the law is clear: "parents cannot, by agreement, limit or abrogate a child's right to support." John, who engaged in "procreative conduct", was established as Jaycee's father, and as such was responsible for her support.

 

Although the court has clarified important issues in regards to surrogacy arrangements, it recognizes the need for legislative action to sort out the parental rights and responsibilities arising out of assisted reproductive technologies, as the UPA is "imperfectly designed."

 

Stage set to replace costly step-parent adoptions with pre-birth judgments

The ramifications of this case are potentially ground-breaking. If one was to expand the holding to cover traditional surrogacy arrangements, one could conclude that because the medical procedures would be initiated and consented to by the intended parents, maternity may be established through a judgment, rather than a step-parent adoption. This is because it could be established by a manner other than those listed in section 7610; adoption being the only option for an intended mother who neither gives birth or uses her genetic material. If one utilizes section 7613 to establish maternity, then the intended mother's consent to the insemination of her husband's sperm into a surrogate would require a simple pre-birth judgment of maternity and paternity to establish her parenthood. Even more fundamentally, the Court's decision signals the possible departure from previously accepted dogma that traditional surrogacy is, and must be, treated differently from gestational surrogacy. Expansion of the Calvert v. Johnson "intent of the parties" approach to traditional surrogacy, will permit otherwise financially strapped infertile couples the opportunity to avail themselves of surrogacy and enjoy the same legal protections as those couples who utilize gestational carriers.

 

It was once urged that when intended parents have no genetic relation to the child, the child is to be "parentless" and the state's responsibility. Now, at least California has enunciated a rule of law that will help avoid such situations; a rule progressive enough to encompass current and anticipated future medical technologies. Equally important, the Buzzanca court has extended comprehensive legal protection to couples considering the use of donated gametes, including oocytes and embryos, in an area which, heretofore, represented a legal black hole. In so doing, California has reasserted its position as arguably the most favorable jurisdiction in the world for infertile couples contemplating the use of assisted reproductive technologies.

March 11, 1998

 

 

*EDITOR'S NOTE:

 

Following the publication of this article, the authors were successful in petitioning the Los Angeles Superior Court for a Judgment of Maternity on behalf of an Intended Mother, who along with her husband (the biological father), worked with a traditional surrogate. The Judgment of Maternity, issued on March 17, 1998, permitted the Intended Mother to finalize her parental rights without having to undergo a step-parent adoption.

 

Consequently, it will no longer be necessary for an Intended Mother to pursue a step-parent adoption and the legal, financial and administrative hardships typically associated with step-parent adoptions. Rather, all Intended Parents can now finalize their parental rights through a Judgment of Maternity & Paternity (in most cases, prior to the birth of their child) regardless of whether they use a traditional or gestational surrogate. This procedure will also allow the initial birth certificate to be issued in the names of the Intended Parents, obviating the need to secure an amended birth certificate.

The elimination of the disparate treatment historically associated with traditional surrogacy will hopefully encourage more couples to consider assisted reproduction as a viable option to begin their families.

 

 

New York State Grant for IVF

IVF Grant Program

New York State residents who meet certain eligibility requirements may be eligible for a grant program for IVF.. The New York State Department of Health has contracted  with a number of fertility centers. For more information contact New York State Department of Health

The phone number is: 518-474-1911.

New York State Grant for IVF

IVF Grant Program

New York State residents who meet certain eligibility requirements may be eligible for a grant program for IVF.. The New York State Department of Health has contracted  with a number of fertility centers. For more information contact New York State Department of Health

INCIID called the New York State grant program to find out about general eligibility requirements but have been unable to get an answer about what the basic requirements are for a grant. We will keep trying. If anyone has information about the NY IVF Grant Program, please contact us or leave a comment.

NYS Infertility Demonstration Program

The program subsidizes higher level infertility treatments in vitro fertilization (IVF) and gamete intra fallopian transfer (GIFT) for privately insured women for whom these procedures are not covered by insurance. The program also includes a subsidy for testicular sperm extraction (TESE). Seventeen providers now participate in the program. Providers who agreed to participate are responsible for billing NYS for costs associated with IVF and GIFT, after patient co-pays and insurance reimbursement, if any, are taken into account. Provider selection was based on published data on infertility providers in NYS (CDC's Assisted Reproductive Technology Success Rates).

For information regarding participating in the NYS Infertility Demonstration Program (IDP) contact an approved NYS IDP provider, link below:

The phone number is: 518-474-1911.

States mandating infertility insurance coverage

Arkansas | California | Connecticut | Hawaii | Illinois | Maryland |
MassachusettsMontana | New York | New Jersey | Ohio | Rhode Island |
Texas | West Virginia | National IVF Scholarships |

 

 

Arkansas

This law requires all health insurers that cover maternity benefits to cover the cost of in vitro fertilization (IVF) Health maintenance organizations, commonly called HMOs, are exempt from the law. Patients need to meet the following conditions in order to get their IVF covered: The patient must be the policyholder or the spouse of the policyholder and be covered by the policy; The patient's eggs must be fertilized with her spouse's sperm; The patient and her spouse must have at least a two-year history of unexplained infertility OR the infertility must be associated with one or more of the following conditions Endometriosis; Fetal exposure to diethylstilbestrol, also known as DES; Blocked or surgically removed fallopian tubes that are not a result of voluntary sterilization; or Abnormal male factors contributing to the infertility.

 

The IVF benefits are subject to the same deductibles and co-insurance payments as maternity benefits. The law also permits insurers to limit coverage to a lifetime maximum of $ 15,000.

(Arkansas Statutes Annotated, Sections 23-85-137 and 23-86-118).

 

California

The California law requires certain insurers to offer coverage for infertility diagnosis and treatment. That means group health insurers covering hospital, medical or surgical expenses must let employers know infertility coverage is available. The law does not require those insurers to provide the coverage; nor does it force employers to include it in their employee insurance plans.

The law defines infertility as:

* The presence of a demonstrated condition recognized by a licensed physician and surgeon as a cause of infertility; or
* The inability to conceive a pregnancy or carry a pregnancy to a live birth after a year or more of sexual relations without contraception.

The law defines treatment as including, but not limited to:
* Diagnosis and diagnostic tests;
* Medication;
* Surgery; and
* Gamete Intrafallopian Transfer, also known as GIFT.

 

The law specifically exempts insurers from having to provide vitro fertilization coverage. Also, the law does not require employers that are religious organizations to offer coverage for treatment that conflicts with the organization's religious and ethical purposes.

(California Health and Safety Code, Section 1374.55).

 

Connecticut

Summary (Oct 2005)

The Act defines infertility as "the condition of a presumably healthy individual who is unable to conceive or produce conception or sustain a successful pregnancy during a oneyear period". The Act provides that covered medically necessary expenses of the diagnosis and treatment of infertility include, but are not limited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryo lavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer.

 

The Act specifies permissible policy limitations, maximums and requirements as follows:

(1) Limit such coverage to an individual until the date of such individual's fortieth birthday;
(2) Limit such coverage for ovulation induction to a lifetime maximum benefit of four cycles
(3) Limit such coverage for intrauterine insemination to a lifetime maximum benefit of three cycles;
(4) Limit lifetime benefits to a maximum of two cycles, with not more than two embryo implantations per cycle, for in-vitro fertilization, gamete intrafallopian transfer, zygote intra-fallopian transfer or low tubal ovum transfer, provided each such fertilization or transfer shall be credited toward such maximum as one cycle;
(5) Limit coverage for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian transfer and low tubal ovum transfer to those individuals who

 

Hawaii

The Hawaii law requires certain insurance plans to provide a one-time only benefit for outpatient costs resulting from in vitro fertilization. Those plans include individual and group health insurance plans, hospital contracts or medical service plan contracts that provide pregnancy-related benefits.

Patients need to meet the following conditions in order to get their IVF covered:
* The patient's eggs must be fertilized with the sperm of the patient's spouse
* The patient or the patient's spouse must have at least a five-year history of infertility;
* The patient has been unable to get and stay pregnant through other infertility treatments covered by insurance;
* The IVF is performed at medical facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists; and
* The infertility must be associated with one or more of the following conditions:
+ Endometriosis;
+ Fetal exposure to diethylstilbestrol, also known as DES;
+ Blocked or surgically removed fallopian tubes; or
+ Abnormal male factors contributing to the infertility.

(Hawaii Revised Statutes, Sections 431-lOA-116.5 and 432.1-604).

 

Illinois

This law requires insurance policies that cover more than 25 people to cover costs of the diagnosis and treatment of infertility. The law defines infertility as the inability to get pregnant after one year of unprotected sex or the inability to carry a pregnancy.

Coverage includes, but is not limited to:
* In vitro fertilization (IVF); Uterine embryo lavage; Embryo transfer;
* Artificial insemination;
* Gamete intrafallopian transfer (GIFT);
* Zygote intrafallopian transfer (ZIFT);
* Intracytoplasmic Sperm Injection (ICSI);
* Four completed egg retrievals per lifetime; and
* Low tubal egg transfer.

Coverage for IVF, GIFT and ZIFT is required only if:
* The patient has used all reasonable, less expensive and medically appropriate treatments and is still unable to get pregnant or carry a pregnancy;
* The patient has not reached the maximum number of allowed egg retrievals;
* The procedures are performed at facilities that conform to standards set by the America Society for

 

Reproductive Medicine or the American College of Obstetricians and Gynecologists.

The law exempts religious organizations which believe the covered procedures violate their teachings and beliefs.

(Illinois Compiled Statutes Annotated, Chapter 215, Sections 5/356m and 125/5-3).

 

Maryland

Updated 7/20/06 per Maryland Insurance Administration

Maryland's law changed in 2000. The law does apply to health maintenance organizations, but it only applies to policies issued in Maryland. It will not apply to residents of Maryland covered under a policy issued in another state. Here is the text of the current law:

(a) This section applies to:

(1) insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies that are issued or delivered in the State; and
(2) health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.

(b)

(1) An entity subject to this section that provides pregnancy-related benefits may not exclude benefits for all outpatient expenses arising from in vitro fertilization procedures performed on the policyholder or subscriber or dependent spouse of the policyholder or subscriber.
(2) The benefits under this subsection shall be provided:

(i) for insurers and nonprofit health service plans, to the same extent as the benefits provided for other pregnancy-related procedures; and
(ii) for health maintenance organizations, to the same extent as the benefits provided for other infertility services.

(c) Subsection (b) of this section applies if:

(1) the patient is the policyholder or subscriber or a covered dependent of the policyholder or subscriber;
(2) the patient's oocytes are fertilized with the patient's spouse's sperm;
(3) (i) the patient and the patient's spouse have a history of infertility of at least 2 years' duration; or
(ii) the infertility is associated with any of the following medical conditions:

1. endometriosis;
2. exposure in utero to diethylstilbestrol, commonly known as DES;
3. blockage of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy); or
4. abnormal male factors, including oligospermia, contributing to the infertility;

(4) the patient has been unable to attain a successful pregnancy through a less costly infertility treatment for which coverage is available under the policy or contract; and
(5) the in vitro fertilization procedures are performed at medical facilities that conform to the American College of Obstetricians and Gynecologists guidelines for in vitro fertilization clinics or to the American Fertility Society minimal standards for programs of in vitro fertilization.

(d) An entity subject to this section may limit coverage of the benefits required under this section to three in vitro fertilization attempts per live birth, not to exceed a maximum lifetime benefit of $100,000.

(e) Notwithstanding any other provision of this section, if the coverage required under this section conflicts with the bona fide religious beliefs and practices of a religious organization, on request of the religious organization, an entity subject to this section shall exclude the coverage otherwise required under this section in a policy or contract with the religious organization.

 

Massachusetts

This state's law requires health maintenance organizations and insurers companies that cover pregnancy-related benefits to cover medically necessary expenses of infertility diagnosis and treatment.

The law defines infertility as "the condition of a presumably healthy individual who is unable to conceive or produce conception during a one-year period."

Benefits covered include:
* Artificial insemination;
* In vitro fertilization;
* Gamete Intrafallopian Transfer;
* Sperm, egg and/or inseminated egg retrieval, to that extent that those costs are not covered by the donor's insurer;
* Intracytoplasmic Sperm Injection (ICSI) for the treatment of male infertility; and
* Zygote Intrafallopian Transfer (ZIFT).

Insurers may, but are not required, to cover experimental procedures, surrogacy, reversal of voluntary sterilization or cryopreservation of eggs.

(Annotated Laws of Massachusetts, Chapters 175,@ 47H; 176A,@8K;176B,@4J; and l76G,@4).

 

Montana

This state's law requires health maintenance organizations (Blue Cross Blue Shield is the only one in Montana) to cover infertility services as part of basic preventive health care services.

The law does not define infertility or the scope of services covered; nor did the state ever draft regulations explaining what infertility services entail. As for health insurers other than HMOs, the law specifically excludes infertility coverage from the required scope of health benefits those insurers must provide.

(Montana Code Annotated, Sections 33-22-1521 and 33-31-102)

 

New Jersey        

The Family Building Act requires insurance policies that cover more than 50 people and provide pregnancy-related benefits to cover the cost of the diagnosis and treatment of infertility. The law defines infertility as the disease or condition that results in the inability to get pregnant after two years of unprotected sex (female partner under the age of 35) or one year of unprotected sex (female partner over the age of 35) or the inability to carry a pregnancy to term. 

 

Coverage includes, but is not limited to: 

  • Diagnosis & diagnostic tests
  • Medications
  • Surgery
  • In vitro fertilization (IVF)
  • Embryo transfer
  • Artificial insemination
  • Gamete intra fallopian transfer (GIFT)
  • Zygote intra fallopian transfer (ZIFT)
  • Intracytoplasmic Sperm Injection (ICSI)
  • Four completed egg retrievals per lifetime

 

Coverage for IVF, GIFT and ZIFT is required only if:

  • The patient has used all reasonable, less expensive and medically appropriate treatments and is still unable to get pregnant or carry a pregnancy;
  • The patient has not reached the maximum number of allowed egg retrievals and the patient is 45 years of age or younger.
  • The procedures are performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

The law allows religious organizations to request an exclusion of this coverage if it is contrary to the religious employer's bona fide religious tenets. (New Jersey Permanent Statutes: 17B:27-46.1X Group Health Insurance Policies; 17:48A-7W Medical Service Corporations; 17:48-6X Hospital Service Corporations; 17:48E-35.22 Health Service Corporations; 26:2J-4.23 Health Maintenance Organizations)

 

New York

The New York law requires insurers to cover the diagnosis and treatment of correctable medical conditions and makes clear that coverage cannot be withheld for a correctable condition solely because the condition results in infertility.

 

However, the law DOES NOT require coverage for the reversal of voluntary sterilization, experimental procedures, or procedures intended solely to produce pregnancy - like IVF.

(New York Consolidated Laws, Insurance, Sections 3216, 3221 and 4303).
New York does have an IVF grant program for state residents.

 

Ohio

Ohio's law requires health maintenance organizations to cover basic preventive health services, including infertility The Ohio Insurance Department has no written definition of infertility services, but the following general interpretation is applied to the code:

Up to $2,000 worth of infertility services are to be covered if the couple experiences an inability to conceive purely as a result of infertility problems (unexplained infertility, for example). The $2,000 cap is not applied if another condition or medically related problem (endometriosis, for example) is involved. Experimental procedures - determined on a case-by-case basis by the Insurance Department --are not covered.

(Ohio Revised Code Annotated, Chapter 1742).

 

Rhode Island

The Rhode Island law requires insurers that cover pregnancy services to cover the cost of medically necessary expenses of diagnosis and treatment of infertility.

The law defines infertility as "the condition of an otherwise healthy married individual who is unable to conceive or produce conception during a period of one year."

The patient's co-payment cannot exceed 20 percent (Rhode Island General Laws @ 27-18-30, 27-19-23, 27-20-20 and 27-41-33).

 

Texas

This state's law requires certain insurers that cover pregnancy services to offer coverage for infertility diagnosis and treatment - including in vitro fertilization. Therefore insurers must let employers know this coverage is available. However, the law does not require those insurers to provide the coverage; nor does it force employers to include it in their health plans.

Patients need to meet the following conditions in order to get their IVF covered:
* The patient must be the policyholder or the spouse of the policyholder and be covered by the policy;
* The patient's eggs must be fertilized with her spouse's sperm;
* The patient has been unable to get and stay pregnant through other infertility treatments covered by insurance;
* The IVF is performed at medical facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists; and
* The patient and her spouse must have at least a continuous five-year history of unexplained infertility,
* OR the infertility must be associated with one or more of the following conditions:
+ Endometriosis.
+ Fetal exposure to diethylstilbestrol (DES);
+ Blocked or surgical removal of one or both fallopian tubes; or
+ Oligospermia

The law does not require organizations that are affiliated with religious groups to cover treatment that conflicts with the organization's religious and ethical beliefs.

(Texas Insurance Code, Article 3.51-6).

 

West Virginia

Mandates HMOs to cover infertility treatment as a preventative benefit. The law does not define "infertility treatment" and HMOs have interpreted the term as excluding IVF. 

Please email us if you have questions or if you have found errors in this data. Thanks!

 

Pregnancy Discrimination Act and How to File

Facts About Pregnancy Discrimination
The Pregnancy Discrimination Act is an amendment to Title VII of the Civil Rights Act of 1964. Discrimination on the basis of pregnancy, childbirth or related medical conditions [including infertility or reproductive failure] constitutes unlawful sex discrimination under Title VII. Women affected by pregnancy or related conditions must be treated in the same manner as other applicants or employees with similar abilities or limitations.

 

Hiring
An employer cannot refuse to hire a woman because of her pregnancy related condition as long as she is able to perform the major functions of her job. An employer cannot refuse to hire her because of its prejudices against pregnant workers or the prejudices of co-workers, clients or customers.

 

Pregnancy and Maternity Leave
An employer may not single out pregnancy related conditions for special procedures to determine an employee's ability to work. However, an employer may use any procedure used to screen other employees' ability to work. For example, if an employer requires its employees to submit a doctor's statement concerning their inability to work before granting leave or paying sick benefits, the employer may require employees affected by pregnancy related conditions to submit such statements.

 

If an employee is temporarily unable to perform her job due to pregnancy, the employer must treat her the same as any other temporarily disabled employee; for example, by providing modified tasks, alternative assignments, disability leave or leave without pay.

 

Pregnant employees must be permitted to work as long as they are able to perform their jobs. If an employee has been absent from work as a result of a pregnancy related condition and recovers, her employer may not require her to remain on leave until the baby's birth. An employer may not have a rule which prohibits an employee from returning to work for a predetermined length of time after childbirth.

 

Employers must hold open a job for a pregnancy related absence the same length of time jobs are held open for employees on sick or disability leave.

 

 

 

******** HEALTH INSURANCE**********

Any health insurance provided by an employer must cover expenses for pregnancy related conditions on the same basis as costs for other medical conditions. Health insurance for expenses arising from abortion is not required, except where the life of the mother is endangered.

 

Pregnancy related expenses should be reimbursed exactly as those incurred for other medical conditions, whether payment is on a fixed basis or a percentage of reasonable and customary charge basis.

The amounts payable by the insurance provider can be limited only to the same extent as costs for other conditions. No additional, increased or larger deductible can be imposed.

 

Employers must provide the same level of health benefits for spouses of male employees as they do for spouses of female employees.

 

Fringe Benefits
Pregnancy related benefits cannot be limited to married employees. In an all-female workforce or job classification, benefits must be provided for pregnancy related conditions if benefits are provided for other medical conditions.

 

If an employer provides any benefits to workers on leave, the employer must provide the same benefits for those on leave for pregnancy related conditions.

Employees with pregnancy related disabilities must be treated the same as other temporarily disabled employees for accrual and crediting of seniority, vacation calculation, pay increases and temporary disability benefits.

 

 

See also: How To File A Charge of Employment Discrimination

 

New York State and Infertility Insurance

01/04/02 - New York State Senate - http://www.senate.state.ny.us

January 23, 2001
Senator Bruno
SENATE PASSES SWEEPING WOMEN'S HEALTH BILLS

Expanded Coverage for Early Cancer Detection, Contraception, Infertility The New York State Senate today passed two measures that dramatically enhance women's access to a broad range of critical health services, including obstetrical/gynecological services, screenings for breast, cervical cancer and osteoporosis, infertility 
treatment and contraceptives. The bills are part of the Senate Majority's comprehensive review of existing state laws concerning New Yorkers' health coverage that is being undertaken by the Senate Majority Task Force on 
Health & Wellness. 

 

"The Senate Majority has long been a forceful advocate for women's health issues, from expanding coverage to help fight women's cancers, to ending the practice of 'drive-thru' mastectomies and requiring coverage for 48-hour hospital stays after giving birth," Senate Majority Leader Joseph L. Bruno said. 

 

" Once again, we are showing the way with comprehensive legislation that further protects and expands women's health services, and helps put New York at the forefront of promoting healthy lives." The Women's Health bill, S. 3, is sponsored by Sen. Bruno, Task Force Co-chairs Sen. John J. Bonacic, Sen. Mary Lou Rath, and members of the Task Force. The infertility measure, S. 1265, is sponsored by Sen. Kenneth P. LaValle, a Task Force member. 

 

BREAST/CERVICAL CANCER SCREENING 
The Women's Health bill expands women's access to mammography and cervical cancer screenings by closing a loophole in earlier laws requiring coverage that exempted some policies. Additionally, it enhances coverage by requiring insurers to pay for breast cancer-detecting mammograms for women beginning at age 40 at least 
annually, based on a doctor's recommendation. Current law requires coverage from age 50. Cancer is the leading cause of death among women and the recovery rate for these diseases is far higher with early detection. 

 

OSTEOPOROSIS EXAMS 
It requires coverage for medically necessary tests, like routine bone density exams, to detect the bone-crippling disease osteoporosis. Current law does not address coverage for osteoporosis, which affects half of women over 50 by gradually weakening their bones. 

 

CONTRACEPTIVE COVERAGE 
Additionally, the measure requires coverage for doctor-prescribed contraceptives. In every case, the expanded coverage would be subject to a policyholder's regular deductibles and co-payments. "New York women comprise half of the state's workforce, but still are forced to pay a disproportionate share of out-of-pocket expenses for 
important medical care and services," said Senator Bonacic (R-Mount Hope). 

 

OBSTETRICS/GYNECOLOGY 
A 1994 state law already requires insurers to cover a woman's visit to the obstetrician/gynecologist of her choice without first requiring a referral from a primary care physician. The Women's Health bill closes technical oopholes in the law to ensure consistent coverage for even more women who belong to HMOs that are currently exempt 
from the requirement. New York already requires coverage for a host of medical exams, including tests for breast and cervical cancers, that are aimed at early detection of potentially fatal diseases, when treatment options offer the best hope for full and healthful recovery. "These earlier efforts have certainly resulted in dramatic declines in the number of women who were previously undiagnosed with often preventable and treatable diseases," said

Senator Rath (R-C, Williamsville). "Women make three-quarters of the health care decisions in American households, and spend almost two or every three health care dollars. This bill increases access and expands critical health services for women; in short, we are ensuring that the caregivers are eligible for care." "Diseases like cancer and osteoporosis take a tremendous toll on New York women, affecting tens of thousands of families each year," said Senate Health Committee Chairman Kemp Hannon (R-Garden City), a Task Force member. "This measure will help women protect themselves from disease by enabling them to take steps early to find and treat illness before it debilitates them." 

 

"Early detection of diseases that affect women can not only save lives, but also spare them from more intrusive and expensive procedures required to treat advanced stages of cancer and other diseases," said Senate Insurance Committee Chairman James L. Seward (R-C, Oneonta). "This measure is the type of forward-thinking plan that not only protects women's health, but also encourages a healthier society." The bill also requires insurers to provide coverage for contraceptives prescribed by a woman's doctor. It is estimated that women under 44 pay 68 percent more in out-of-pocket medical expenses than men, largely due to health costs including contraception, though 90 percent of HMOs cover the costs of some of these services. 

 

At least 20 states already require coverage for routine, doctor-prescribed contraceptives. Like many of these states, the Women's Health measure includes a carefully crafted opt-out provision for health care plans and providers with moral or religious objections to providing the additional coverage. The Women's Health measure stems from the ongoing study of health and wellness issues by the Task Force, which has been conducting roundtable discussions across the state to gather information 
and expert testimony from health professionals, providers, health officials and others. 

 

INFERTILITY 
The infertility bill mirrors a bill passed last year by the Senate that would require insurers to provide coverage for those aged 25 to 44 for procedures that are recognized and sanctioned by leading medical specialists. 

"As many as one out of five couples are known to have experienced difficulty in having children, and this legislation removes the often frustrating financial obstacles to those couples gaining access to procedures and treatments that are known to be effective," said Senator LaValle (R-C, Port Jefferson). Coverage for infertility treatment is already offered to many insured, including over 200,000 state workers, who have seen no premium increase associated with the cost of covering the procedures. 
Senator Bruno said the Majority Task Force on Health & Wellness would continue its work with the goal of proposing measures and initiatives that will encourage healthier lifestyles, enhanced efforts at disease prevention and better health treatment for the sick. 

Other Task Force members include Sens. John R. Kuhl (R-C, Hammondsport), William Larkin (R-C, New Windsor), Dean G. Skelos (R, Rockville Centre), Nancy Larraine Hoffmann (R, Syracuse), Nicholas Spano (R, Yonkers), Roy M. Goodman (R, Manhattan) and Thomas P. Morahan (R-C, New City).

 

States Mandating Insurance Coverage for Infertility and Pregnancy Loss

Arkansas

This law requires all health insurers that cover maternity benefits to cover the cost of in vitro fertilization (IVF) Health maintenance organizations, commonly called HMOs, are exempt from the law.

Patients need to meet the following conditions in order to get their IVF covered:

 

  • The patient must be the policyholder or the spouse of the policyholder and be covered by the policy;
  • The patient's eggs must be fertilized with her spouse's sperm;
  • The patient and her spouse must have at least a two-year history of unexplained infertility,
  • OR the infertility must be associated with one or more of the following conditions:
    • Endometriosis;
    • Fetal exposure to diethylstilbestrol, also known as DES;
    • Blocked or surgically removed fallopian tubes that are not a result of voluntary sterilization; or
    • Abnormal male factors contributing to the infertility.

 

The IVF benefits are subject to the same deductibles and co-insurance payments as maternity benefits. The law also permits insurers to limit coverage to a lifetime maximum of $ 15,000.

(Arkansas Statutes Annotated, Sections 23-85-137 and 23-86-118).

 

Maryland

The Maryland law requires health and hospital insurance policies that provide pregnancy benefits to also cover the cost of in-vitro fertilization. However, the law does not apply to health maintenance organizations, or HMOs. Policies that must provide the coverage include those covering people who live and work in the state, regardless of whether the policy is issued in or outside the state.

Patients need to meet the following conditions in order to get their IVF covered:

 

  • The patient's eggs must be fertilized with the sperm of the patient's spouse;
  • The patient is unable to get pregnant through less expensive covered treatments;
  • The IVF is performed at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.
  • The patient and his or her spouse must have at least a five-year history of infertility;
  • OR their infertility must be associated with one or more of the following conditions:
    • Endometriosis;
    • Fetal exposure to diethylstilbestrol, also known as DES; or
    • Blocked or surgically removed fallopian tubes.

 

Regulations that took effect in 1994 exempt businesses with 50 or fewer employers from having to provide the IVF coverage.

(Annotated Code of Maryland, Article 48A, Sections 354DD, 470W and 477EE).

 

Massachusetts

This state's law requires health maintenance organizations and insurers companies that cover pregnancy-related benefits to cover medically necessary expenses of infertility diagnosis and treatment.

The law defines infertility as "the condition of a presumably healthy individual who is unable to conceive or produce conception during a one-year period."

Benefits covered include:

 

  • Artificial insemination;
  • In vitro fertilization;
  • Gamete Intrafallopian Transfer;
  • Sperm, egg and/or inseminated egg retrieval, to that extent that those costs are not covered by the donor's insurer;
  • Intracytoplasmic Sperm Injection (ICSI) for the treatment of male infertility; and
  • Zygote Intrafallopian Transfer (ZIFT).
  •  

Insurers may, but are not required, to cover experimental procedures, surrogacy, reversal of voluntary sterilization or cryopreservation of eggs.

(Annotated Laws of Massachusetts, Chapters 175,@ 47H; 176A,@8K;176B,@4J; and l76G,@4).

 

Montana

This state's law requires health maintenance organizations (Blue Cross Blue Shield is the only one in Montana) to cover infertility services as part of basic preventive health care services.

The law does not define infertility or the scope of services covered; nor did the state ever draft regulations explaining what infertility services entail. As for health insurers other than HMOs, the law specifically excludes infertility coverage from the required scope of health benefits those insurers must provide.

(Montana Code Annotated, Sections 33-22-1521 and 33-31-102)

 

New York

The New York law requires insurers to cover the diagnosis and treatment of correctable medical conditions and makes clear that coverage cannot be withheld for a correctable condition solely because the condition results in infertility.

 

However, the law DOES NOT require coverage for the reversal of voluntary sterilization, experimental procedures, or procedures intended solely to produce pregnancy - like IVF.

(New York Consolidated Laws, Insurance, Sections 3216, 3221 and 4303).

 

Ohio

Ohio's law requires health maintenance organizations to cover basic preventive health services, including infertility

 

The Ohio Insurance Department has no written definition of infertility services, but the following general interpretation is applied to the code:

 

Up to $2,000 worth of infertility services are to be covered if the couple experiences an inability to conceive purely as a result of infertility problems (unexplained infertility, for example). The $2,000 cap is not applied if another condition or medically related problem (endometriosis, for example) is involved. Experimental procedures - determined on a case-by-case basis by the Insurance Department -- are not covered.

(Ohio Revised Code Annotated, Chapter 1742).

 

Rhode Island

The Rhode Island law requires insurers that cover pregnancy services to cover the cost of medically necessary expenses of diagnosis and treatment of infertility.

 

The law defines infertility as "the condition of an otherwise healthy married individual who is unable to conceive or produce conception during a period of one year."

 

The patient's co-payment cannot exceed 20 percent (Rhode Island General Laws @ 27-18-30, 27-19-23, 27-20-20 and 27-41-33).

 

Texas

This state's law requires certain insurers that cover pregnancy services to offer coverage for infertility diagnosis and treatment - including in vitro fertilization. Therefore insurers must let employers know this coverage is available. However, the law does not require those insurers to provide the coverage; nor does it force employers to include it in their health plans.

Patients need to meet the following conditions in order to get their IVF covered:

 

  • The patient must be the policyholder or the spouse of the policyholder and be covered by the policy;
  • The patient's eggs must be fertilized with her spouse's sperm;
  • The patient has been unable to get and stay pregnant through other infertility treatments covered by insurance;
  • The IVF is performed at medical facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists; and
  • The patient and her spouse must have at least a continuous five-year history of unexplained infertility,
  • OR the infertility must be associated with one or more of the following conditions:
    • Endometriosis.
    • Fetal exposure to diethylstilbestrol (DES);
    • Blocked or surgical removal of one or both fallopian tubes; or
    • Oligospermia

 

The law does not require organizations that are affiliated with religious groups to cover treatment that conflicts with the organization's religious and ethical beliefs.

(Texas Insurance Code, Article 3.51-6).

 

Insurance Advocacy Forum

In the United States, one of the richest and most technically advanced nations on earth, millions of couples remain involuntarily childless. A conservative estimate places the number of U.S. couples that grapple with infertility annually at 5,000,000, yet less than 20% of those couples will undergo some form of definitive treatment. The high cost of infertility treatment, especially the advanced Assisted Reproductive Technologies (ART) such as In Vitro Fertilization (IVF), has resulted in reluctance on the part of most insurance companies to provide benefits for infertility and therefore, has rendered such medical intervention financially inaccessible to the general infertile population. Although a few states have enacted legislation requiring health insurance providers to offer or provide infertility benefits, such coverage is often limited, or absent altogether due to regulatory loopholes. The majority of employer groups as well as health insurance providers continue to avoid voluntarily including infertility benefits. They recognize that such benefits would spawn an increase in the demand for these specialized services. This fuels their fear of the spiraling costs that might be brought about by a disproportionate increase in the demand for expensive ART, and the costly neonatal services required to deal with the potential influx of premature babies resulting from IVF-related multiple births.

 

Visit the insurance Advocacy forum on INCIID

 

What you should know about Managed Care Insurance

Provider or Managed Care Networks
(HMOs, PPOs)

 

 

Staff Model HMO --- provides health services through a physician group controlled by the HMO
Physicians participating in the staff model HMO are salaried employees of the HMO and spend their time providing services exclusively to HMO enrollees. These providers are salaried and although there may be a bonus system for the physicians, the HMO is at financial risk for the entire cost of health care services being rendered to the HMO’s members.

 

Group Model HMO --- In most group model HMOs, the HMO contracts with multi specialty physician groups to provide all physician services to the HMO’s members. These physicians are not employees of an HMO and are typically paid via monthly capitation checks.

 

IPA (Independent Practice Association) Model HMO ---provides services through direct contact with physicians in independent medical practices. The IPA model HMO contracts with several physician groups, which in turn contract with individual physicians to provide healthcare for the HMO's enrollees. These individual physicians may continue to see non-HMO patients. Enrollees sign-up with a specific IPA or medical group when they join the HMO. Although the HMO may contract with thousands of physicians, enrollees may only have access to those that are members of the particular medical group/IPA. In most cases, physicians are paid on a capitated basis.

 

Fee-for-Service

This is the traditional kind of health care policy. Insurance companies pay fees for the services provided to the insured people covered by the policy. This type of health insurance offers the most choices of doctors and hospitals. You can choose any doctor you wish and change doctors any time. You can go to any hospital in any part of the country.

With fee-for-service, the insurer only pays for part of your doctor and hospital bills. 
This is what you pay:

  • A monthly fee, called a premium.
  • A certain amount of money each year, known as the deductible, before the insurance payments begin.

 

In a typical plan, the deductible might be $250 for each person in your family, with a family deductible of $500 when at least two people in the family have reached the individual deductible. The deductible requirement applies each year of the policy. Also, not all health expenses you have count toward your deductible. Only those covered by the policy do.

 

You need to check the insurance policy to find out which ones are covered. After you have paid your deductible amount for the year, you share the bill with the insurance company. For example, you might pay 20 percent while the insurer pays 80 percent. Your portion is called coinsurance.

To receive payment for fee-for-service claims, you may have to fill out forms and send them to your insurer. Sometimes your doctor's office will do this for you. You also need to keep receipts for drugs and other medical costs.

 

You are responsible for keeping track of your medical expenses. There are limits as to how much an insurance company will pay for your claim if both you and your spouse file for it under two different group insurance plans. A coordination of benefit clause usually limits benefits under two plans to no more than 100 percent of the claim.

Most fee-for-service plans have a "cap," the most you will have to pay for medical bills in any one year. You reach the cap when your out-of-pocket expenses (for your deductible and your coinsurance) total a certain amount. It may be as low as $1,000 or as high as $5,000. Then the insurance company pays the full amount in excess of the cap for the items your policy says it will cover. The cap does not include what you pay for your monthly premium.

 

Some services are limited or not covered at all. You need to check on preventive health care coverage such as immunizations and well-child care.

 

There are two kinds of fee-for-service coverage: basic and major medical.

Basic protection pays toward the costs of a hospital room and care while you are in the hospital. It covers some hospital services and supplies, such as x-rays and prescribed medicine. Basic coverage also pays toward the cost of surgery, whether it is performed in or out of the hospital, and for some doctor visits.

Major medical insurance takes over where your basic coverage leaves off. It covers the cost of long, high-cost illnesses or injuries. Some policies combine basic and major medical coverage into one plan. This is sometimes called a "comprehensive plan." Check your policy to make sure you have both kinds of protection.

 

What Is a "Customary" Fee?

Most insurance plans will pay only what they call a reasonable and customary fee for a particular service. If your doctor charges $1,000 for a hernia repair while most doctors in your area charge only $600, you will be billed for the $400 difference. This is in addition to the deductible and coinsurance you would be expected to pay.

To avoid this additional cost, ask your doctor to accept your insurance company's payment as full payment. Or shop around to find a doctor who will. Otherwise you will have to pay the rest yourself.

 

Questions to Ask About Fee-for-Service Insurance

  1. How much is the monthly premium?
  2. What will your total cost be each year?
  3. Are there individual rates and family rates.
  4. What does the policy cover?
  5. Does it cover prescription drugs, out-of-hospital care, or home care?
  6. Are there limits on the amount or the number of days the company will pay for these services?
  7. The best plans cover a broad range of services.
  8. Are you currently being treated for a medical condition that may not be covered under your new plan?
  9. Are there limitations or a waiting period involved in the coverage?
  10. What is the deductible? Often, you can lower your monthly health insurance premium by buying a policy with a higher yearly deductible amount.
  11. What is the coinsurance rate?
  12. What percent of your bills for allowable services will you have to pay?
  13. What is the maximum you would pay out of pocket per year?
  14. How much would it cost you directly before the insurance company would pay everything else?
  15. Is there a lifetime maximum cap the insurer will pay?
  16. The cap is an amount after which the insurance company won't pay anymore. This is important to know if you or someone in your family has an illness that requires expensive treatments.

 

The preferred provider organization is a combination of traditional fee-for-service and an HMO. Like an HMO, there are a limited number of doctors and hospitals to choose from. When you use those providers (sometimes called"preferred" providers, other times called "network" providers), most of your medical bills are covered.

When you go to doctors in the PPO, you present a card and do not have to fill out forms. Usually there is a small copayment for each visit. For some services, you may have to pay a deductible and coinsurance.

As with an HMO, a PPO requires that you choose a primary care doctor to monitor your health care. Most PPOs cover preventive care. This usually includes visits to the doctor, well-baby care, immunizations, and mammograms.

 

In a PPO, you can use doctors who are not part of the plan and still receive some coverage. At these times, you will pay a larger portion of the bill yourself (and also fill out the claims forms). Some people like this option because even if their doctor is not a part of the network, it means they don't have to change doctors to join a PPO.

 

Questions to Ask About a PPOs

 

  1. Are there many doctors to choose from?
  2. Who are the doctors in the PPO network?
  3. Where are they located?
  4. Which ones are accepting new patients?
  5. How are referrals to specialists handled?
  6. What hospitals are available through the PPO?
  7. Where is the nearest hospital in the PPO network?
  8. What arrangements does the PPO have for handling emergency care?
  9. What services are covered?
  10. What preventive services are offered?
  11. Are there limits on medical tests, out-of-hospital care, mental health care, prescription drugs, or other services that are important to you?
  12. What will the PPO plan cost?
  13. How much is the premium?
  14. Is there a per-visit cost for seeing PPO doctors or other types of copayments for services?
  15. What is the difference in cost between using doctors in the PPO network and those outside it?
  16. What is the deductible and coinsurance rate for care outside of the PPO?
  17. Is there a limit to the maximum you would pay out of pocket? 

 

 

Health Maintenance Organizations (HMOs)

 

Health maintenance organizations are prepaid health plans. As an HMO member, you pay a monthly premium. In exchange, the HMO provides comprehensive care for you and your family, including doctors' visits, hospital stays, emergency care, surgery, lab tests, x-rays, and therapy.

 

The HMO arranges for this care either directly in its own group practice and/or through doctors and other health care professionals under contract. Usually, your choices of doctors and hospitals are limited to those that have agreements with the HMO to provide care. However, exceptions are made in emergencies or when medically necessary.

 

There may be a small copayment for each office visit, such as $5 for a doctor's visit or $25 for hospital emergency room treatment. Your total medical costs will likely be lower and more predictable in an HMO than with fee-for-service insurance.

 

Because HMOs receive a fixed fee for your covered medical care, it is in their interest to make sure you get basic health care for problems before they become serious. HMOs typically provide preventive care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals.

 

The range of services covered vary in HMOs, so it isimportant to compare available plans. Some services, such as outpatient mental health care, often are provided only on a limited basis.

 

Many people like HMOs because they do not require claim forms for office visits or hospital stays. Instead, members present a card, like a credit card, at the doctor's office or hospital. However, in an HMO you may have to wait longer for an appointment than you would with a fee-for-service plan.

 

In some HMOs, doctors are salaried and they all have offices in an HMO building at one or more locations in your community as part of a prepaid group practice. In others, independent groups of doctors contract with the HMO to take care of patients. These are called individual practice associations (IPAs) and they are made up of private physicians in private offices who agree to care for HMO members. You select a doctor from a list of participating physicians that make up the IPA network. If you are thinking of switching into an IPA-type of HMO, ask your doctor if he or she participates in the plan.

 

In almost all HMOs, you either are assigned or you choose one doctor to serve as your primary care doctor. This doctor monitors your health and provides most of your medical care, referring you to specialists and other health care professionals as needed. You usually cannot see a specialist without a referral from your primary care doctor who is expected to manage the care you receive. This is one way that HMOs can limit your choice.

Before choosing an HMO, it is a good idea to talk to people you know who are enrolled in it. Ask them how they like the services and care given.

 

Questions to Ask About an HMO

 

  1. Are there many doctors to choose from?
  2. Do you select from a list of contract physicians or from the available staff of a group practice?
  3. Which doctors are accepting new patients?
  4. How hard is it to change doctors if you decide you want someone else?
  5. How are referrals to specialists handled?
  6. Is it easy to get appointments?
  7. How far in advance must routine visits be scheduled?
  8. What arrangements does the HMO have for handling emergency care?
  9. Does the HMO offer the services I want?
  10. What preventive services are provided?
  11. Are there limits on medical tests, surgery, mental health care, home care, or other support offered?
  12. What if you need a special service not provided by the HMO?
  13. What is the service area of the HMO?
  14. Where are the facilities located in your community that serve HMO members?
  15. How convenient to your home and workplace are the doctors, hospitals, and emergency care centers that make up the HMO network?
  16. What happens if you or a family member are out of town and need medical treatment?
  17. What will the HMO plan cost?
  18. What is the yearly total for monthly fees?
  19. In addition, are there copayments for office visits, emergency care, prescribed drugs, or other services?
  20. How much?

 

 

 

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