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(HealthNewsDigest.com) – Since the 1980s, 15 states—Arkansas, California, Connecticut, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Montana, New Jersey, New York, Ohio, Rhode Island, Texas and West Virginia—have passed laws that require insurers to either cover or offer coverage for infertility diagnosis and treatment. Whether you live in one of these states or if your employer offers infertility benefits, here are the important things to know during this open enrollment period:
Find out if your company is self-funded or fully-funded.
Self-funded employers are exempt from the state mandate if they choose to build their own plan, so it is important to determine if you qualify for state-mandated fertility coverage. In a self-funded plan, the costs of medical care are carried by the employer on a pay-as-they-go basis and the employer or union (known as the plan sponsor) decides what services are covered. If you are not sure if your employer or union is self-insured, ask your benefits manager or union representative. You may also contact the federal Department of Labor, which regulates self-insured plans. You should check your specific state requirement.
Basic Plan Coverage – What does my plan cover?
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Is infertility treatment covered on your plan? Sometimes plans only cover diagnostics and not treatment.
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Intrauterine insemination (IUI)? Do you have to undergo IUI before IVF treatment?
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IVF treatment. Is it covered?
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The use of donor eggs or sperm. Are they covered?
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Gestational carriers? Is this covered?
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Understand if any criteria needs to be met prior to accessing coverage.
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Is there a lifetime maximum of dollars to spend on fertility treatment? If so, what is the dollar amount?
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Are medications included in the lifetime max? (example: meds can run $3-8k per cycle)
Deductibles
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Is there a medical and pharmacy deductible to meet? Many patients are surprised there is a pharmacy deductible to meet as well as their medical deductible.
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Understand what services or testing go towards meeting plan deductible
For end of year planning
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Make sure you do not lose any funds that are available in your HRA (Health Reimbursement Account) or flexible spending account. You may be able to use these funds for diagnostic testing that will be valid for 6-12 months at your fertility practice for upcoming treatment. In an HRA, you will lose money at end of the year if the funds are not spent. In a flexible spending account, some money may roll over into following year, but this varies by employer. HSA (Health Savings Account) money rolls over from year to year.
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Find out treatment costs at the fertility practice of your choice so you can fund your flexible spending account and/or HRA/HSA accordingly
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Be aware of any HRA exclusions that your employer may have put in place.
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