Reply to Open enrollment decisions--what would you do?

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[quote=Anonymous]This is the OP with an update. Sorry in advance if this is long.

I spent an hour on the phone today with Insurance #1 trying to confirm my benefits. Bottom line is that while my plan says that it covers 90% of treatment for the underlying condition causing infertility and artificial insemination, it seems it may be a lot more difficult to get them to pay up.

When I gave CPT codes today for both IUI and IVF to have them check on the coverage, the call rep told me that these codes were subject to "predetermination under my policy." I asked what that meant and the rep told me that the doctor would need to show medical necessity. I asked what that meant exactly and if there were any particular conditions that would need to be met (i.e. certain diagnoses, we needed to be "trying" for a certain period of time, etc.).

The rep's supervisor was gone for the day (I asked to speak to her) but she did her best to figure it out and called several other departments. When she came back she said she had spoken to their "Clinical Services Team" and basically said that for those procedures the way it works is that my doc would need to send all my info (i.e. diagnosis, medical history, treatment plan, etc.) to their Clinical Services Team and they would  decide in 2-15 business days if these procedures would be covered under my plan and that they and only they could determine coverage--so via phone she had no way of telling me if IUI would actually be covered.

Then, contrast that with the fact that my current plan with Insurance #2, which does not cover infertility, is actually covering all of my testing (it's being coded as endometriosis)--including all my bloodwork, an ultrasound, and an HSG test--at 100%. They will also cover the visits to a RE for endometroisis as long as they are not coded for infertility. And the call reps are lovely every time I call--which is never the case with Insurance #1, which is just one misinformed person after another.

So now I am wondering if I just stay on my current plan, have my PCOS treated by the RE, and start saving up big for IVF if we end up needing it in a year. I have read from a lot of people on these boards that IUI is a waste of time so I'm not sure DH and I would pursue it. And even if we did, we probably would wait a while and save up $ for it.

I don't know...I'm really confused now....What does DCUM think? [/quote]

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