Kaiser - Infertility Services DO count toward OOP Max

[Anonymous]

I have it in writing that infertility services do count toward the catastrophic protection out-of-pocket maximum under the 2016 High Option. I reached out to the enrollment representative, Edwin Abarca, and asked to have such confirmation in writing.

Best of luck to you all this coming year.

[Anonymous]

But not the standard option?

[Anonymous]

I only asked about the High Option because it has a lower OOP max (and so, I will use that pretty quickly, which ends up being a substantial savings). I would recommend folks reach out about the Standard Option and get it in writing, if necessary, as I did.

[Anonymous]

Here's the email I sent, if it helps someone:

Dear Mr. Abarca,

My name is [blank], and I am a federal government employee. The federal government is currently undergoing open season, and I am considering switching to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (E32 High Option – Self and Family). I need your assistance to clarify coverage.

The 2016 High Option plan, according to publication RI 73-047, covers infertility services. According to Section 5(a), under page 32, many infertility services are covered up to 50% of Kaiser’s allowance.

In addition, the 2016 High Option plan has a catastrophic protection out-of-pocket maximum of $4,500 per family enrollment. Section 4 of the plan explains that “[a]fter your cost-sharing total $2,250 per person up to $4,500 per family enrollment . . . , you do not have to pay any more certain covered services.” The plan also states that “copayments and coinsurance for the following services do not count toward [the] catastrophic protection out-of-pocket maximum, and [the member] must continue to pay copayments and coinsurance for these services: (1) Acupuncture services; (2) Dental services, except accidental injury dental benefit services; (3) orthopedic devices; and (4) travel benefit.” This list of exceptions, however, does not include infertility services.

In addition, the Summary of Benefits answers the question, “What is not included in the out-of-pocket limit?” In response, it says: “Premiums, balance-billed charges, and health care this plan doesn’t cover.” It does not exclude infertility services from this list.

My understanding, based on the documents provided and my conversation with member services, is that infertility services do count toward the catastrophic protection out-of-pocket maximum under the 2016 High Option. I have looked through both the 2016 Mid Atlantic Summary of Benefits and Coverage (available here: http://healthplans.kaiserpermanente.org/federalemployees/wp-content/uploads/sites/2/2015/09/2016-MidAtlantic-Summary-of-Benefits-and-Coverage.pdf) and the 2016 Mid Atlantic Plan Brochure (available here: http://healthplans.kaiserpermanente.org/federalemployees/wp-content/uploads/sites/2/2015/09/2016-MidAtlantic-Plan-Brochure.pdf), and nothing in these documents seems to indicate that infertility services are not counted toward the catastrophic protection out-of-pocket maximum.

If you could please point me to where I can find information showing that infertility services are not counted toward the catastrophic protection out-of-pocket maximum, I would greatly appreciate it. Otherwise, please confirm both via phone [phone number] and via letter [address] that infertility services indeed count toward the catastrophic protection out-of-pocket maximum under the 2016 Mid Atlantic High Plan. If they do, I will happily switch from [current provider] over to Kaiser Permanente.

[Anonymous]

FYI -- Mr. Abarca is the person that contracts with the federal government in the Mid-Atlantic States area. He's basically the supervisor of all Member services.

[Anonymous]

This very helpful!
Thank you sharing

Do folks know if the OOP max include prescriptions?

[Anonymous]

From what I read, I believe prescriptions have a separate $2000 max (I'm not OP).

[Anonymous]

This is so helpful. Do you happen to have an email address for Mr. Abarca?

[Anonymous]

Here's his email address: [e-mail], per OPM's website.

And here's the written confirmation I received:

Hi [blank],

Our enrollment representative Edwin Abarca, forwarded your email question to me.
Yes, you are correct Infertility services does count toward the catastrophic protection outofpocket
maximum under the 2016 High Option.

Therefore once your OOPM is met there is no other cost sharing up to your $100,000 benefit limit.
Please let me know if any additional information is needed.

Thank you,
Beverlee Dawkins
Kaiser Permanente
Federal Government Accounts.
2101 E. Jefferson Street, 6E
Rockville, MD 20852

[Anonymous]

I also confirmed that infertility services and injectable medication like ovulation stimulants count towards the out of pocket maximum up until the $100,000 benefit limit. Thanks OP for figuring this out, I missed it initially.

[Anonymous]

A few more answers from Kaiser:


Q) What is the basis for Kaiser’s determination that it will only cover 50% of the cost from the brochures? There doesn’t seem to be anything in the brochures that would support that, given the language I pointed out.

A) Per the brochure, which you refer to within your original email: The 2016 High Option plan, according to publication RI-73-047, covers infertility drugs. According to Section 5(a), under page 33, it says to see “Section 5(f), Prescription Drug benefits, for coverage of fertility drugs,” and Section 5(f), under page 65, states that “fertility drugs for covered infertility treatments” are covered at “50% of [Kaiser’s] allowance.”
(This would then indicate the 50 % cost share that is the remaining patient responsibility.)


Q) Does that mean that fertility drugs do not count towards the out-of-pocket maximum?;

A) Fertility drug costs DO count toward the out-of-pocket-max.


Q) Does that mean that even if I reach the OOP max under the plan (be it because of services or because of fertility drugs), that I will always be responsible for 50% of the cost of the fertility drugs?

A) No, once your out-of-pocket max is reached, all applicable services which apply to the catastrophic max are covered by the health plan.

This seems to indicate to me that fertility drugs will be covered at 100% after you reach your out-of-pocket maximum, but I sent an additional question to confirm. I hope this helps everyone.

[Anonymous]

Thank you!
I assume to count towards the OOP max, we will need to fill our prescriptions with Kaiser?
There have been other posts about lower cost options for fertility drugs.

[Anonymous]

GREAT NEWS. I just got it confirmed that after OOP is reached, Kaiser will cover fertility drugs at 100%. Here's the response I received:

Members are responsible for 50% of the allowance for infertility treatment and fertility drugs for covered infertility treatments. Both infertility drugs and treatment apply towards the out-of-pocket maximum. Therefore, after copayments and coinsurance total the applicable amount of the out-of pocket maximum, services and drugs would be covered at 100%.

I hope this answers your question.

[Anonymous]

Those who have been in contact with Kaiser - can you share who you contacted, how, and how long it took you to hear from them? I sent an email yesterday to Mr. Albarca asking a question concerning my son's ability to see specialists at Children's national as I did not see those pediatric specialists listed on Kaiser's list of providers. I want to be sure his care can continue and obviously am running up against the clock as we all have to wrap up our decisions and make our elections by Monday.

I'm switching to Kaiser for infertility coverage myself (DS was product of IVF #2 at SGFC).

[Anonymous]

Greetings and thank you OP for providing this information. It is frustrating that Kaiser is not consistent in its response to whether infertility services count towards the OOP max. I spent an hour on the phone yesterday, being told that it does not count towards the OOP max. I asked that they send it to me in writing and the individual refused. When I asked for a supervisor, they transferred me and the person that picked up the phone pretended she could not hear me, but stayed on the line over 3 mintues... urghhh, I will be writing them a letter... for several reasons!