The International Council on Infertility Information Dissemination, Inc

Understanding your health insurance

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.

 

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

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 planHMO, 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

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.

 

 

 

 

Infertility Insurance: What is an HMO?

What is a Health Maintenance Organization (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?

 

Outcome Based Reporting: View the beta testing sites here

Historically, IVF treatment results have been reported with a focus upon age as the primary differentiating factor in terms of expected outcome. However, there are well known and defined factors that affect IVF outcome in addition to the age of the egg provider and the type of procedure performed. The Outcome Based Reporting System (OBRS™) is a computerized IVF-specific data collection system that provides reliable IVF outcome data in real time. Results for conventional IVF (with the patient’s own eggs) are presented in separate categories by age, each of which is further divided into four (4) subgroups (A through D) based on relative Categories of Complexity using the following variables that are known to affect outcome:

 

  • The number of prior failed IVF attempts;
  • Ovarian reserve as measured by:

(1) FSH blood level on the 3rd day of the menstrual cycle,

(2) Follicular response of the ovaries to stimulation with specific dosages of gonadotropins, and

(3) Number of eggs recovered at retrieval; and

(4) Type of IVF procedure performed, e.g., fresh cycle using own eggs versus fresh cycle using ovum donor-derived eggs, and the use of thawed embryos for transfer (frozen embryo transfers- FET)

 

OBRS™ ensures accurate representation of all cases undergoing embryo transfer (the “denominator of outcome”) for statistical computation. The outcomes are updated every 3 months to ensure that all ongoing pregnancies (beyond the 1st trimester) are accurately represented. It is only through a process such as OBRS™ that it is possible, against the background of relevant demographic, clinical, and laboratory variables (that affect IVF outcome), to verifiably present statistics in a manner that permits reasonable case-to-case comparison without having to compare “apples with oranges”.

 

OBRS™ will be utilized by the participating ART program(s) with the requirement that only those IVF cases that have been fully registered/logged into the data collection system at the onset of ovarian stimulation with fertility agents will be eligible for inclusion. This requirement will ensure that the most important variable, namely accurate representation of all cases undertaken (the “denominator of outcome”), is available for statistical computation. A validated denominator, together with a validated outcome (the numerator), will permit proper computation of the pregnancy rate for each Category of Complexity in order to allow greater specificity, i.e., an “apples-to-apples” comparison of outcome data and thus, enhanced predictive value of the data.

 

There are 5 anonymous Beta Testing Sites (Clinics) currently testing the system using categories of complexity. You can view the outcome based IVF statistical pregnancy data here:

 

http://www.ivfstats.org/

 

PreTreatment with IVIg Letter to Insurance

TEMPLATE LETTER OF PRE-TREATMENT MEDICAL NECESSITY
AND/OR POST-TREATMENT ROUTINE APPEAL

 
 
TO WHOM IT MAY CONCERN:
 
RE:
 
 
            High dose intravenous immunoglobulin (IVIg) therapy is clinically beneficial and not experimental in a variety of immune disorders associated with human reproductive failure and pregnancy.  Examples include: autoimmune diseases, Rh sensitization, hypogammaglobulinemia, recurrent fetal loss and infertility associated with antiphospholipid antibodies, intrauterine growth retardation and idiopathic thrombocytopenia.  The effects of high dose immunoglobulin infusion include:
 

  • Feedback inhibition of antibody synthesis
  • Down regulation of EDGE Fcg receptor
  • Blockage of placental transport of maternal endogenous Edge
  • Regulation of idiotype network
  • Alteration of T and B lymphocyte functions
  • Down regulation of natural killer cell function and tumor necrosis factor secretion.

           

            The beneficial effects of this medication are documented in the literature involving treatment for autoimmune disorders, organ transplant and bone marrow rejection and autoimmune disorders associated with infertility and pregnancy. Therefore, its use can no longer be labeled as experimental.
 
           

            Women with the autoimmune disorder antiphospholipid antibody syndrome are at risk of infertility and should they conceive, will often experience recurrent pregnancy losses, intrauterine growth retardation, intrauterine fetal death, and maternal complications such as thrombosis (arterial and venous), stroke and transient ischemic episodes.  More than one third of infertile women have circulating antiphospholipid antibodies and antithyroid antibodies that may prevent or impair implantation by compromising syncitalization of the early trophoblast and/or causing local venous and arterial thrombosis. The administration of IVIg in association with infertility treatment and during subsequent pregnancy is often the only method by which reproductive failure can be avoided.
 
Women at risk of pregnancy complications show alterations in their immunophenotype lymphocyte sets particularly in elevations in CD56+ natural killer cells that secrete tumor necrosis factor (TNF).  This factor results in decidual necrosis, death of the placental cells, coagulopathy and eventual death of the infant.  The only medication effective in reducing these natural killer cells and TNF secretion is IVIg.  Other corticosteroids or immunosuppressants are either ineffective or contraindicated during pregnancy.
 
This patient will continue to be at risk of serious complications without IVIg therapy.
 

 

Sincerely,
 
 
 
 
 
REFERENCES

 
1.       de la C-mara C, Arrieta R, Gonz-lez A, Iglesias E, Ome-aca F.  High dose intravenous immunoglobulin as the sole prenatal treatment for severe Rh immunization.  N Engl J Med  

          1988;318:519-520.
 
2.       Smith CIE, Hammarstrom L.  Intravenous immunoglobulin in pregnancy.  Obstet Gynecol 1985;66:39s.
 
3.       Scott JR, Branch W, Kochenour NK, Ward K.  Intravenous immunoglobulin treatment of pregnant patients with recurrent pregnancy loss caused by antiphospholipid antibodies

          and Rh immunization.  Am J Obstet Gynecol 1988;159:1055-1056.
 
4.       Parke A, Maier D, Wilson D, Andreoli J, Ballow M.  Intravenous gammaglobulin, antiphospholipid antibodies, and pregnancy.  Ann Int Med 1989;110:495-496.
 
5.       Rose V, Gordon Ll.  Idiopathic thrombocytopenic purpura in pregnancy.  Successful management with immunoglobulin infusion.  JAMA 1985;254:2626-2628.
 
6.       Bussell JB, Pham LC, Aledort L, Nachman R.  Maintenance treatment of adults with refractory immune thrombocytopenic purpura using repeated intravenous infusions of gamma

          globulin.  Blood 1988;72:121-127.
 
7.       Mannhalter JW, Ahmad R, Wolf HM, Eibl MM.  Effect of polymeric Edge on human monocyte functions.  Int Arch Allergy Appl Immunol 1987;82:159-167.
 
8.       Sultan Y, Maisonneuve P, Kazatchkine MD, Nydegger UE.  Anti-idiotypic suppression of autoantibodies to factor VIII b high dose intravenous gammaglobulin.  Lancet 1984;i:765-

          768.
 
9.       Sher G, Feinman M, Zouves C, Kuttner G, Maassarani G, Salem R, Matzner W, Ching W, Chong P.  High fecundity rates following in vitro fertilization and embryo transfer

          (IVF/ET) in antiphospholipid antibody (APA) seropositve women treated with heparin and aspirin.  Human Reproduction  1994;11.
 
10.     Tsubakio T, Kurato Y, Katageri S, et al.  Alteration in T cell subset and immunoglobulin synthesis in vitro during high dose gammaglobulin therapy in patients with idiopathic

          thrombocytopenic purpura.  Clin Exp Immunol  1983;53:697-702.
 
11.     Wapner RJ, Cowchock SF, Shapiro SS.  Successful treatment in two women with antiphospholipid antibodies and refractory pregnancy losses with intravenous immunoglobulin

          infusions.  Am J Obstet Gynecol 1989;161:1271-1272.
 
12.     Kwak JYH, Gilman-Sachs A, Beaman KD, Beer AE.  Reproductive outcome in women with recurrent spontaneous abortions of alloimmune and autoimmune etiologies; pre vs.

          post conception treatment.  Am J Ostet Gynecol 1992;166:1975-1987.
 
13.     Kwak JYH, Gilman-Sachs A, Beaman KD, Beer AE.  Autoantibodies in women with primary recurrent spontaneous abortion of unknown etiology.  J. Reprod Immunol 1992;22:15-

         31.
 

Children First: Making the Paradigm Shift from Infertility to Adoption By Patricia Irwin Johnston, MS

Moving from infertility to adoptive parenting is a complicated emotional process. In transferring from the process and the culture of infertility and its treatment to the process and culture of adoption, consumers are expected to make a huge shift. The Barrier? Medical treatment is centered on the needs and wishes of the paying-client—the adult who wanted a baby (that’s you!). Adoption’s culture is centered on the needs and best interests of the one client who has no say in the process and who bears no financial responsibility—the child (not you!) Adoption is child-centered rather than adult-centered. But you, one of three clients in the picture, will carry all of the financial risk and burden.

Not fair, you say? I understand. Been there. Felt that. But as my children by adoption have grown up, as our relationships with them and some of their birthparents have developed, I’ve changed my thinking a lot.

Here’s something you probably don’t understand if you are not yet a parent. Parenting itself changes everything. From the moment you become a parent forward, your child’s needs will always come before yours and before anyone else’s in your life. For those who conceive their children, that shift comes automatically as part of the pregnancy experience. Indeed, it’s that shift in thinking that makes it possible for birthparents to plan an adoption.

For those who adopt, however, making that shift is not automatic. Unless one makes a deliberate choice to shift thinking, to participate in an adoption expectancy period, the shift won’t likely happen until after the child arrives. And by then, many infertile couples can have made some pretty bad choices already—choices rooted in their frustration, in their reactions to many losses that infertility has brought to them, in the desperation they have begun to feel about ever being able to parent.

Over the past twenty years or so, changes in adoption have done little more than move the locus of power in adoptions. First power was moved from adoption professionals to adoptive parents, and now it has been transferred to birthparents. But changes in who holds the power have not often included the education necessary for all of these parties to understand and accept what children themselves need from adoption. And what is it that children need? They need well-prepared, unafraid, stable and loving families over their entire lifetimes!

Too many of those involved in adoption right now seem to experience it as a competition. Agencies compete with other agencies and with independent service providers to draw in limited numbers of birthparents whose healthy babies can be offered to an apparently unlimited supply of prospective adopters. Special needs agencies compete with one another for public and private grant money, and often trash one another and their differing approaches to counseling and preparation. Prospective adopters compete with other prospective adopters for the opportunity to adopt available babies. They look for too many shortcuts to “faster” placements by looking for providers who will not require education, extensive preparation, and screening, because it is too “invasive and unfair.” Adopters attempt to demonstrate to expectant parents that their adoptive family would offer a "better" life for the child about to be born than would the child’s family of origin or any other prospective adopters. When an expectant parent has a change of heart about adoption during the window of time a state or province grants for the change-of-mind process, many adopters and their professional advisors take the stance that possession-is-nine-points-of-the-law and go to court so that they might "keep" the baby, even though they are not yet the legal parents. Adopters, birthmothers and professionals often conspire to keep birthfathers and their families out of the picture entirely.

Ideally, changing adoption so that it really meets the needs of children would begin with fundamental changes in thinking and in the law. Different thinking would end the adversarial aura that surrounds adoption. If adoptions really kept the child's interests center-stage, everybody involved in any untimely pregnancy would be seeking the best possible solution for the child to be born. This solution would find him with his permanent family (birth or adoptive) as soon as possible after his birth.

Getting off to this kind of a "clean" start in an adoption, however, demands a tremendous amount of understanding and emotional work on the part of both sets of parents, as well as careful judgment on the part of well trained and well informed professionals. Those working to launch a child-centered adoption must be helped to understand how each of the decisions made and each of the procedures followed will help the child at the adoption's core.

For a baby's launch to be optimal, everyone involved must be committed to being honest with everyone else in the adoption. Birthparents must be honest with one another, with helping professionals, and with prospective adopters. Adopters must be scrupulously honest with professionals and expectant parents. Intermediaries must be scrupulously honest with expectant parents and prospective adoptive parents. There must be no assumptions that “leaving that little something out” “letting that little something go,” causes no harm. Scrupulous adherence to ethical standards that keep the child at the center while respecting the needs and interests of both adoptive parents and birthparents is absolutely crucial in making all decisions concerning an adoption.

As an adoptive parent, wife, sister-in-law, daughter-in-law, cousin-in-law, sister-in-open-adoption to my child’s birthmother, and adoption educator, I hold those who elect to join to adopt to very high standards. That’s because this is what children deserve from their parents.

Patricia Irwin Johnston. is an INCIID Advisory Board Member. She is a long-time advocate, infertility and adoption educator and author of several books, including Adopting after Infertility, Launching a Baby’s Adoption, and INCIID’s own Adoption Is a Family Affair, written with the participation of the INCIID community members on two of the forums which Pat moderates: Exploring and Expecting through Adoption.

Contact Information:

Phone: (317) 872-3055

Email: patjohnston@perspectivespress.com

Website: http://www.perspectivespress.com

History of Data Collection and Statistics and IVF

FACT SHEET:
IVF CONSUMER DATA HISTORY

1984
The Society for Assisted Reproductive Technology (SART) is established at a meeting of the American Fertility Society. At the time, it is named the "IVF Special Interest Group" in order to report only pooled data of its membership (no clinic-specific data) for inclusion in the IVF Registry

1985
In response to complaints regarding exploitation and unscrupulous practices in the area of infertility, and IVF in particular, the United States Congress starts hearings under the auspices of the Office of Technology Assessment (OT A) to address
consumer concerns.

1989
Office of Technology Assessment (OT A) proceedings and conclusions published in the "Wyden Report". Congress subsequently mandates -- under threat of prosecution -- that all IVF programs in the United States report their ART outcome statistics for 1987. The first report of clinic-specific ART outcome statistics in the U.S. is published.

1992
Congress passes the "IVF Success Rate Certification Act of 1992" -- which is implemented in 1997 -- to compel honest disclosure of IVF success rates and quality assurance in all IVF programs

1994
SART gives tacit support to introduction of an "audit" of all its member programs. Peat, Marwick & Company engaged to develop and implement a clinic-specific-IVFoutcome based reporting process. This is abandoned before year-end.

Subsequent gestures to introduce alternative methods for appropriate verification of IVF outcome reporting lead to current "Self-Reporting Process" with "token" random and sporadically conducted onsite reviews

2002
SART sends letter to all IVF Program Directors in the U.S. stating that as a result of "lack of financial and human resources," random onsite reviews of outcome data would not be done for 2002. Instead, IVF facility Medical Directors to perform a "self-review" of medical and laboratory records of ten (10) pre-selected IVF clinic cases. Upon receipt, the center would pass certification and the programs' total, selfgenerated IVF outcome date for the year 2000 would be published on the Center for Disease Control's (CDC) website.

Press Release: Class Action Law Suit Filed Against Blue Cross Blue Shield of California

October 26, 2007

PRESS RELEASE

[For Immediate Release]

 

A lawsuit charging Blue Cross of California with failing to offer infertility benefits required by California law was certified as a class action on Tuesday.  This will allow the class representative and her attorneys to seek an injunction directing Blue Cross to offer much broader infertility coverage to group health plans covering employees of governmental entities and many religious institutions.  Blue Cross currently offers only a limited benefit of $2,500 a year, and requires plan members to pay 50% co-pays.

According to attorney Mark F. Didak of Los Angeles, who represents the class, California Health & Safety Code and Insurance Code require health plans to offer infertility coverage on the same terms as they cover other health conditions, without lower coverage limits or higher co-pays.  “The benefit should cover all infertility diagnosis and treatment services ‘consistent with established medical practices,’” Didak said, “except that health plan providers are not required to offer coverage for the actual laboratory procedures involved in in vitro fertilization.”  The last part is important, says Didak, because health insurers typically refuse to pay for anything associated with in vitro fertilization, which can cost anywhere from $10,000 to $25,000 per cycle.  “The law only allows them to not offer coverage for the lab procedures, which usually cost between a few hundred dollars and $1,500.”  Didak hopes to persuade the court to issue an injunction that might serve as an example to the health insurance industry by clarifying what infertility benefits must be offered and which ones they can choose not to offer.

The lawsuit was filed in 2006 by plaintiff Deborah Dunn Yeager and is pending before Judge Victoria Chaney of the Los Angeles Superior Court.  Prof. Dunn Yeager, who teaches communications at Westmont College in Santa Barbara, enrolled in a Blue Cross plan at work believing it covered infertility problems, only to have her benefits claim denied.  Her college, she discovered, had not been offered infertility coverage on the terms required byCalifornia law.  The statutes, Health & Safety Code section 1374.55 and Insurance Code section 10119.6, also mandate that “every plan shall communicate the availability of that coverage to all group contractholders and to all prospective group contractholders with whom they are negotiating.”

Up to 15% of all couples of child-bearing age suffer problems conceiving.  The problems are often treatable, many times with relatively inexpensive methods.  “When the California Legislature passed the law requiring health plans to offer this coverage in 1989, they found that infertility ‘affects millions of Californians,’” said Mr. Didak. “The Legislature also found that ‘[i]f properly treated, successful pregnancies can result in 70 percent of [infertility] cases,’ but that ‘[i]nsurance coverage for infertility is uneven, inconsistent, and frequently subject to arbitrary decisions which are not based on legitimate medical considerations.’”

Mr. Didak continued, “what’s clear is that if infertility coverage is always offered as the law requires, it will be sold more often, solving the problems the Legislature was trying to address.  It will also bring the price of coverage down as more and more groups purchase it.  Blue Cross will no longer be able to deny necessary medical treatment to people who want the chance to start a family or have another child.  It’s one of the most fundamental rights any person has.”

 

[For more information, please contact class counsel Mark F. Didak at (310) 689-7022 or mdidak@selmanbreitman.com.]

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