Evolution Benefits presentation template

1
Understanding the Connecticut Fertility
Mandate Questions for Insurance Companies
Employers May 8, 2006 Financial Services
Representatives
The Center for Advanced Reproductive Services
2
About the Mandate

• Mandate requires an infertility diagnosis
• Some of what the mandate says is open to the
  interpretation of individual insurance plans
• Definition of ovulation induction (clomid vs.
  injectibles
• Definition of IVF cycle
• Mandate requires that covered treatments are
  clinically indicated
• Exhausting covered benefits does not mean one
  will be moved on to the next level of treatment

3
Mandate Related Questions

• 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)?
• 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?

4
Mandate Related Questions

• Confirm eligibility for
• 4 ovulation inductions (how is your plan defining
  ovulation induction clomid, injectibles?)
• 3 intrauterine inseminations
• 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

5
General Questions for your insurance
company(mandate and non-mandate)

• 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?

6
Questions about blood work

• Is diagnostic blood work covered?
• Estradiol, FSH, LH, Hep BC, HIV
• Is monitoring blood work covered?
• Estradiol, FSH, LH, Progesterone
• Is blood work for genetic testing covered?
• Chromosomes Cystic Fibrosis, Tay Sachs
• Am I required to use specific labs?

7
Questions about diagnostic testing procedures

• Will my new patient visit be covered?
• Will any of the following be covered?
• Semen analysis
• Hysterosalpingogram or Sonohysterogram
• Endometrial biopsy
• Transvaginal ultrasounds
• Diagnostic
• Monitoring as part of cycle

8
Questions about IUI treatment

• Do I have coverage for intrauterine inseminations
  aka artificial inseminations?
• Is prior authorization required?
• Is there
• A maximum number of cycles? Does the maximum
  include all treatment cycles?
• A dollar amount maximum?
• Coverage for sperm washing?

9
Questions about IVF Treatment

• Do I have coverage for In Vitro Fertilization?
• Is prior authorization required?
• Is there
• A maximum number of cycles? Does this maximum
  include all treatment cycles?
• A dollar amount maximum per year or lifetime?

10
Questions about Embryology Lab Procedures

• 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

11
Questions about Medications

• Do I have a separate pharmacy carrier?
• Do I have coverage for oral medications (ie,
  clomid)?
• Do I have coverage for injectible medications?
• Bravelle, Follistim, Gonal F
• Is prior authorization required for my
  medications?
• Do I need to utilize a specific pharmacy?

12
In Closing

• If unable to access this information from your
  insurance company contact your benefits
  administrator thru your employer
• Dont 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.

13
Questions and Answers

• Thank you!