Transcript Evolution Benefits presentation template

Understanding the Connecticut
Fertility Mandate
The Center for Advanced
Reproductive Services
Questions for Insurance Companies &
Employers
May 8, 2006
Financial Services Representatives
About the Mandate
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Mandate requires an infertility diagnosis
Some of what the mandate says is open to the
interpretation of individual insurance plans
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Definition of ovulation induction (clomid vs. injectibles
Definition of IVF cycle
Mandate requires that covered treatments are
clinically indicated
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Exhausting covered benefits does not mean one will be moved on
to the next level of treatment
The Center for Advanced
Reproductive Services
Mandate Related Questions
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Am I covered under the CT mandate passed on 10/1/05?
Is my policy self funded or fully insured?
When am I eligible to access my infertility benefit under the
mandate?
Do I need to complete the Disclosure Form (individual plan
holders)?
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If so, where do I send it?
Does my partner need to complete one?
Is there a fertility look back clause associated with my
policy?
The Center for Advanced
Reproductive Services
Mandate Related Questions
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Confirm eligibility for:
 4 ovulation inductions (how is your plan defining
ovulation induction; clomid, injectibles?)
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3 intrauterine inseminations
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2 IVF cycles (How is your plan defining an IVF cycle?)
– Do FET cycles count toward the 2?
– When does the clock start ticking (what constitutes
one cycle)?
» Start of meds
» Completed retrieval
» Completed transfer
The Center for Advanced
Reproductive Services
General Questions for your insurance company
(mandate and non-mandate)
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Do I have infertility benefits
Do I need a referral?
What is my co-pay for a specialist office visit?
Effective date of my policy
Renewal date of my policy
Is there a deductible or co-insurance?
The Center for Advanced
Reproductive Services
Questions about blood work
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Is diagnostic blood work covered?
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Is monitoring blood work covered?
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Estradiol, FSH, LH, Progesterone
Is blood work for genetic testing covered?
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Estradiol, FSH, LH, Hep B&C, HIV
Chromosomes; Cystic Fibrosis, Tay Sachs
Am I required to use specific labs?
The Center for Advanced
Reproductive Services
Questions about diagnostic testing procedures
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Will my new patient visit be covered?
Will any of the following be covered?:
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Semen analysis
Hysterosalpingogram or Sonohysterogram
Endometrial biopsy
Transvaginal ultrasounds
– Diagnostic
– Monitoring as part of cycle
The Center for Advanced
Reproductive Services
Questions about IUI treatment
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Do I have coverage for intrauterine inseminations aka
artificial inseminations?
Is prior authorization required?
Is there:
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A maximum number of cycles? Does the maximum include
all treatment cycles?
A dollar amount maximum?
Coverage for sperm washing?
The Center for Advanced
Reproductive Services
Questions about IVF Treatment
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Do I have coverage for In Vitro Fertilization?
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Is prior authorization required?
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Is there:
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A maximum number of cycles? Does this maximum
include all treatment cycles?
A dollar amount maximum per year or lifetime?
The Center for Advanced
Reproductive Services
Questions about Embryology Lab Procedures
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Is there coverage for Intracytoplasmic Sperm Injection
(ICSI)? CPT codes 89280 or 89281
Is there coverage for Assisted Hatching?
CPT code 89253
Is there coverage for Cryopreservation of embryo(s)?
CPT code 89258
Is there coverage for Cryopreservation of sperm?
CPT code 89259
The Center for Advanced
Reproductive Services
Questions about Medications
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Do I have a separate pharmacy carrier?
Do I have coverage for oral medications (ie, clomid)?
Do I have coverage for injectible medications?
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Bravelle, Follistim, Gonal F
Is prior authorization required for my medications?
Do I need to utilize a specific pharmacy?
The Center for Advanced
Reproductive Services
In Closing
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If unable to access this information from your insurance
company contact your benefits administrator thru your
employer
Don’t take “no” for an answer or a first response as the final
word. Request to speak to a supervisor
Your doctors office has experienced people to help you
obtain information and help you understand it. However,
ultimately we cannot guarantee benefits. Benefits are
between patients and their insurance company.
The Center for Advanced
Reproductive Services
Questions and Answers
Thank you!
The Center for Advanced
Reproductive Services