DC Government insurance coverage options for IVF

[Anonymous]

I am a District employee and will be starting IVF soon. Has anyone else done IVF on a DC government medical insurance plan and have feedback? I'm currently on the Aetna HMO, and it appears that there is some IVF coverage under the Aetna HMO, Aetna PPO, United, and Kaiser policies. I'm trying to get my head around the coverage terms for each, and would appreciate any feedback or BTDT perspectives.

Thanks!

[Anonymous]

Not recent but I was using Aetne in 2012 DC govt for IVF. It may have changed but read if very carefully. I think they covered "50% of the the procedure" and that is very narrowly defined. Medications were not covered and were easily 5-6k out of pocket. Also, the specific injection of spern into egg process was not covered. I think it really just covered retrieval and transfer. Luckily it worked on the first try but we still spent probably 15k out of pocket all in.

[Anonymous]

Following as I'm a DC Government employee as well. Last time around I had Aetna HMO and they covered 50% for infertility services and did not cover meds. I got lucky on my third IUI and paid for meds OOP. I'm older this time around and am looking for the best coverage if I do end up needing IVF. It's infuriating how vague the summary sheets are regarding infertility and they make it really hard to get correct information.

[Anonymous]

Anonymous wrote:Following as I'm a DC Government employee as well. Last time around I had Aetna HMO and they covered 50% for infertility services and did not cover meds. I got lucky on my third IUI and paid for meds OOP. I'm older this time around and am looking for the best coverage if I do end up needing IVF. It's infuriating how vague the summary sheets are regarding infertility and they make it really hard to get correct information.

OP here - any idea if your infertility treatments applied to the out of pocket max last time? I'm on the Aetna HMO now and thinking of switching, but I have the feeling that all of the plans have similar benefits. I emailed DCHR with a list of fertility benefit coverage questions and would be happy to share the answers if you want to post a throw away email.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Following as I'm a DC Government employee as well. Last time around I had Aetna HMO and they covered 50% for infertility services and did not cover meds. I got lucky on my third IUI and paid for meds OOP. I'm older this time around and am looking for the best coverage if I do end up needing IVF. It's infuriating how vague the summary sheets are regarding infertility and they make it really hard to get correct information.

OP here - any idea if your infertility treatments applied to the out of pocket max last time? I'm on the Aetna HMO now and thinking of switching, but I have the feeling that all of the plans have similar benefits. I emailed DCHR with a list of fertility benefit coverage questions and would be happy to share the answers if you want to post a throw away email.

PP here. I have no idea if it applied to the out of pocket max so I'm sorry I can't help there. I'd love the answers to those questions! Last year when I called HR about this they were really unhelpful and clueless.

[e-mail]

Thanks!

[Anonymous]

I would also love the answers to those questions. I'm considering switching to my partner's plan. He works for DCGov and is not getting many answers. I currently have no coverage through my employer.

[Anonymous]

OP here - I've only gotten a response back from UHC so far, but below is what they provided. It's more flexible coverage (no restrictions on types of services, etc.), but it will be easy to hit the $30,000 limit quickly. I've heard of people paying for meds out of pocket, then saving the insurance coverage for the actual cycles/services.

From Aetna:

There is a $30,00 lifetime maximum for infertility coverage; and the benefit is based on the dollar limit, not number of cycles. Coverage is at 50% of the eligible expenses/provider’s contracted rate. The plan covers infertility medications, and fertility treatments and medications both count toward the annual out of pocket maximum ($3,500). Cryopreservation of embryos is covered.

Prior Authorization Requirement
You must obtain prior authorization as soon as possible. If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses.


Services for the treatment of infertility when provided by or under the direction of a Physician, limited to the following procedures:
? Ovulation induction.
? Insemination procedures (artificial insemination (AI) and intrauterine insemination (IUI)).
? Assisted Reproductive Technologies (ART).
? Pharmaceutical Products for the treatment of infertility that are administered on an outpatient basis in a Hospital, Alternate Facility, Physician's office, or in a Covered Person's home.

To be eligible for Benefits, the Covered Person must meet all of the following:
? Have failed to achieve a Pregnancy after a year of regular, unprotected intercourse if the woman is under age 35, or after six months, if the woman is over age 35.
? Be under age 44, if female.
? Have infertility that is not related to voluntary sterilization or failed reversal of voluntary sterilization

[Anonymous]

OP again. Here's the response from Kaiser. Still waiting on Aetna.

There is a $100,000.00 lifetime maximum or 3 attempts per lifetime. Infertility services and all meds (injectible and non-injectible) are covered at 50%. Fertility services do NOT count toward the annual out of pocket maximum, and freezing and cryopreservation is excluded from coverage.

What counts as a cycle? If a cycle is not completed it does not count ( such as if there is stimulation but there is not egg development sometimes this is changed to an IUI cycle. That would not count as an IVF cycle. The initial part of an IVF cycle is achieved when eggs are retrieved. When an embryo is transferred it can be fresh or a frozen and thawed embryo. A patient is entitled to three embryo transfers. The cycles for IUI and IVF are counted separately.

[Anonymous]

Anonymous wrote:OP here - I've only gotten a response back from UHC so far, but below is what they provided. It's more flexible coverage (no restrictions on types of services, etc.), but it will be easy to hit the $30,000 limit quickly. I've heard of people paying for meds out of pocket, then saving the insurance coverage for the actual cycles/services.

From Aetna:

There is a $30,00 lifetime maximum for infertility coverage; and the benefit is based on the dollar limit, not number of cycles. Coverage is at 50% of the eligible expenses/provider’s contracted rate. The plan covers infertility medications, and fertility treatments and medications both count toward the annual out of pocket maximum ($3,500). Cryopreservation of embryos is covered.

Prior Authorization Requirement
You must obtain prior authorization as soon as possible. If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses.

Just to clarify, you said the above is from Aetna but you talked to UHC. So is the above UHC? I really appreciate this info!

Services for the treatment of infertility when provided by or under the direction of a Physician, limited to the following procedures:
? Ovulation induction.
? Insemination procedures (artificial insemination (AI) and intrauterine insemination (IUI)).
? Assisted Reproductive Technologies (ART).
? Pharmaceutical Products for the treatment of infertility that are administered on an outpatient basis in a Hospital, Alternate Facility, Physician's office, or in a Covered Person's home.

To be eligible for Benefits, the Covered Person must meet all of the following:
? Have failed to achieve a Pregnancy after a year of regular, unprotected intercourse if the woman is under age 35, or after six months, if the woman is over age 35.
? Be under age 44, if female.
? Have infertility that is not related to voluntary sterilization or failed reversal of voluntary sterilization

[Anonymous]

Anonymous wrote:

Anonymous wrote:OP here - I've only gotten a response back from UHC so far, but below is what they provided. It's more flexible coverage (no restrictions on types of services, etc.), but it will be easy to hit the $30,000 limit quickly. I've heard of people paying for meds out of pocket, then saving the insurance coverage for the actual cycles/services.

From Aetna:

There is a $30,00 lifetime maximum for infertility coverage; and the benefit is based on the dollar limit, not number of cycles. Coverage is at 50% of the eligible expenses/provider’s contracted rate. The plan covers infertility medications, and fertility treatments and medications both count toward the annual out of pocket maximum ($3,500). Cryopreservation of embryos is covered.

Prior Authorization Requirement
You must obtain prior authorization as soon as possible. If you fail to obtain prior authorization as required, Benefits will be reduced to 50% of Eligible Expenses.

Just to clarify, you said the above is from Aetna but you talked to UHC. So is the above UHC? I really appreciate this info!

Services for the treatment of infertility when provided by or under the direction of a Physician, limited to the following procedures:
? Ovulation induction.
? Insemination procedures (artificial insemination (AI) and intrauterine insemination (IUI)).
? Assisted Reproductive Technologies (ART).
? Pharmaceutical Products for the treatment of infertility that are administered on an outpatient basis in a Hospital, Alternate Facility, Physician's office, or in a Covered Person's home.

To be eligible for Benefits, the Covered Person must meet all of the following:
? Have failed to achieve a Pregnancy after a year of regular, unprotected intercourse if the woman is under age 35, or after six months, if the woman is over age 35.
? Be under age 44, if female.
? Have infertility that is not related to voluntary sterilization or failed reversal of voluntary sterilization

Sorry I quoted without my question earlier. Just to clarify, you said the above is from Aetna but you also said you talked to UHC. So is the above UHC? I really appreciate this info! Dealing with DC Government HR is a nightmare.

[Anonymous]

OP again, yes, sorry! First response was from UHC, second from Kaiser. Haven't heard from Aetna. FWIW, I expect the Aetna coverage to be similar to Kaiser (with the exclusions and restrictions), so I think we're going to go with UHC.

[Anonymous]

So helpful, I am also trying to get these same answers. I will post here for all your benefit if I hear from Aetna, which I am planning to call directly.

[Anonymous]

OP, did you ever hear back from Aetna? If so, are HMO benefits for infertility different than PPO?

For UHC, based on your write-up, does it mean you have to first shell out $3500 OOP before they will begin to cover 50% of covered services? And if you do not get prior authorization they say they will only cover 50% of services but they already do that so how is this a penalty? Maybe I missed something. Thanks!

[Anonymous]

OP here - I did not hear back from Aetna, but did get preapproved by them for IVF, so based on what they told the clinic, here's my understanding of the Aetna coverage (HMO, though I think the PPO is the same/similar):

There is no lifetime maximum, the IUIs are covered at 50% with no limit on the number and IVF coverage is capped at 3 attempts per lifetime. HOWEVER, see what counts as a cycle below AND note that "per lifetime" means any prior attempts, including any self pay or with another insurance carrier. Infertility services are covered at 50%. Comprehensive fertility services (medicated TI, IUI) do NOT count toward the annual out of pocket maximum, but IVF DOES count toward the OOP max. All meds (injectible and non-injectible), freezing, and cryopreservation are excluded from coverage. Things like ICSI and other testing are covered (at

What counts as a cycle? The cycles for IUI and IVF are counted separately. A retrieval + freeze all cycle, frozen embryo transfer, and retrieval + fresh transfer all count as separate cycles. This means that if the clinic decides to do a freeze all and frozen transfer (which my clinic does 60% of the time), then that counts as 2 of your 3 cycles.


OP again here - my take is that if you want to do multiple IUIs, the Aetna plans give you more coverage than UHC (I don't really want to switch to Kaiser, so didn't closely compare that option). However, you'll be paying 50% of the IUI, plus meds for all cycles. Once you switch to IVF, you'll pay the first $3,500 until you hit the OOP, then you'll be covered at 100% for the remaining cycles. But you will still have to pay for meds ($3-5k per cycle) and storage ($1,200 per cycle and $500 once a year for storage) OOP because they are totally excluded from coerage. Because a cycle that is a retrieval then frozen transfer counts as two cycles, it's likely you'll exhaust your 3 cycles before you'd hit UHC's $30k limit. If you have PCOS or otherwise expect to bank a lot of embryos your first retrieval, then your math may work differently. We'll likely need multiple retrievals, so the Aetna plan would give me fewer total cycles and each cycle would cost more.

Phew, I've been reading the contracts and putting fake scenarios into budgeting spreadsheets for weeks. I hope this is helpful for others!

[Anonymous]

Anonymous wrote:OP, did you ever hear back from Aetna? If so, are HMO benefits for infertility different than PPO?

For UHC, based on your write-up, does it mean you have to first shell out $3500 OOP before they will begin to cover 50% of covered services? And if you do not get prior authorization they say they will only cover 50% of services but they already do that so how is this a penalty? Maybe I missed something. Thanks!

No, it means the opposite. You pay 50% until you've paid $3,500, then you don't pay anymore. So if a procedure is $1,000, you pay $500 7 times until it reaches $3,500, then you don't have to pay anything for the 8th time. The preauthorization thing means they'll deny coverage for anything that requires preauthorization. Since infertility treatment (versus diagnosis) requires preauthorization, anything coded as infertility will be denied.