Infertility services usually not covered

I am currently insured in the state of Maine and the plan does not cover fertility treatment. My two sisters and I have a genetic condition which makes it impossible to conceive on our own. I am disgusted that my insurance does not recognize this as a medical condition. What do you have to do to get Maine to recognize this and require insurance companies to help cover infertility?   There are already 15 states that require their insurance companies to do this. One in 10 women has trouble conceiving or staying pregnant. Reproductive organs should be treated no different than other vital organs in the body. It is an elephant in the room that no one seems to want to address.

Ready For A Family

Dear Ready For A Family,

Dear Ready For A Family,

It comes down to the definition of “health” and “medically necessary care”.

Insurance covers medically necessary care, which is generally defined as care needed to restore proper functioning of the body.  If your inherited condition impairs the reproductive system, treatment to restore its proper functioning would be considered medically necessary.  Treatment could include surgery, for example but would not include in-vitro fertilization.

If proper functioning cannot be restored and your only option to conceive is fertility treatment, then the plan is within its contract to refuse to pay.  This is because conceiving a child is not considered medically necessary.

Assuming that your treatment is to restore proper functioning, you should not give up on having insurance pay for it.  After the plan turns down your claim, you can ask them to reconsider it.  The letter they send with their denial will tell you how to “appeal” their decision.  Take the steps to appeal it with your doctor’s help.  You will want a letter from your doctor explaining that the care is medically necessary.  If they reconsider and still turn you down, you can go further and have an outside review.  The letter with their second decision will tell you how to get an outside review.  This outside review process is required under the Affordable Care Act.

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Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.