Insurance: How do they define "infertility"?

[Anonymous]

I am about to switch to MD insurance to get mandated IVF coverage. However, I see in my ins. plans that with no specific diagnosis (endo, blocked tubes, severe MF, etc.) I need to have been infertile for the most recent two years of marriage.

I have been trying for 2 years but experienced two pregnancy losses. That is, I did conceive in the past two years, but this didn't result in a pregnancy (past 12 weeks and past 4 weeks in my case).

My question is this: do you know if I'd fall under their definition of "infertile"? Has anyone here been covered with losses in the most recent two years of trying?

Thanks!

[Anonymous]

You need to contact the insurer directly and ask this question. Insurers will have different definitions of "infertility," and what we say may not apply in your case.

[Anonymous]

I think as long as you have been trying for 2 years you will meet the definition. I would also call and ask.

[Anonymous]

Thanks. I've called and because I'm not yet a member, they can't tell me for sure. I've spoken to everyone else I can think of and can't get a definite answer.

If anyone was in a similar situation and in MD, please let me know!

[Anonymous]

Anonymous wrote:Thanks. I've called and because I'm not yet a member, they can't tell me for sure. I've spoken to everyone else I can think of and can't get a definite answer.

If anyone was in a similar situation and in MD, please let me know!

I had the same problem. I tried to find out if switching would get me coverage for injectibles and they couldn't tell me because I wasn't a member, very frustrating. Are you seeing an RE? Their financial office might have a better idea of your specific insurance's requirements.

[Anonymous]

If you plan to do IVF at Shady Grove they have insurance specialists who will take care of all of this for you.

[Anonymous]

This is almost always defined as "trying for six months after age 35" or "trying for 12 months until age 35". If you've been TTC for two years, you'll qualify. Often, you are required to do a certain number of IUIs (sometimes just one) before moving on to IVF, however.

[Anonymous]

PP here -- pregnancy loss is not relevant, typically. I also had two miscarriages during my 18mo of TTC, and I easily qualified.

[Anonymous]

I think the 2 years requirement is coming from the Maryland law. Here is the section regarding required coverage for IVF:


§ 15-810. Benefits for in vitro fertilization.



(a) Scope of section.- 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) Exclusion of benefits prohibited.-

(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) Conditions for provision of benefits.- 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) Limitations on benefits.- 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) Exclusion for bona fide religious beliefs and practices.- 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.

[Anonymous]

it depends on the plan. MDIPA requires you to be trying for 2 years prior to IVF unless you meet one of their diagnostic criteria (documented male factor infertility is one such example).
They don't require you to do IUIs prior to IVF.