understanding the connecticut fertility mandate questions for insurance companies & employers...

Understanding the Connecticut Understanding the Connecticut Fertility MandateFertility Mandate

Questions for Insurance Companies & Questions for Insurance Companies & EmployersEmployers

May 8, 2006May 8, 2006

Financial Services RepresentativesFinancial Services Representatives

The Center for Advanced The Center for Advanced Reproductive ServicesReproductive Services


About the Mandate About the Mandate

Mandate requires an infertility diagnosisMandate requires an infertility diagnosis Some of what the mandate says is open to the Some of what the mandate says is open to the

interpretation of individual insurance plans interpretation of individual insurance plans Definition of ovulation induction (clomid vs. injectiblesDefinition of ovulation induction (clomid vs. injectibles Definition of IVF cycleDefinition of IVF cycle

Mandate requires that covered treatments are Mandate requires that covered treatments are clinically indicatedclinically indicated Exhausting covered benefits does not mean one will be moved on Exhausting covered benefits does not mean one will be moved on

to the next level of treatmentto the next level of treatment


Mandate Related QuestionsMandate Related Questions

Am I covered under the CT mandate passed on 10/1/05?Am I covered under the CT mandate passed on 10/1/05? Is my policy self funded or fully insured?Is my policy self funded or fully insured? When am I eligible to access my infertility benefit under the When am I eligible to access my infertility benefit under the

mandate?mandate? Do I need to complete the Disclosure Form (individual plan Do I need to complete the Disclosure Form (individual plan

holders)?holders)? If so, where do I send it?If so, where do I send it? Does my partner need to complete one?Does my partner need to complete one?

Is there a fertility look back clause associated with my Is there a fertility look back clause associated with my policy?policy?


Mandate Related QuestionsMandate Related Questions

Confirm eligibility for:Confirm eligibility for: 4 ovulation inductions (how is your plan defining ovulation 4 ovulation inductions (how is your plan defining ovulation

induction; clomid, injectibles?)induction; clomid, injectibles?)

3 intrauterine inseminations3 intrauterine inseminations

2 IVF cycles (How is your plan defining an IVF cycle?)2 IVF cycles (How is your plan defining an IVF cycle?)– Do FET cycles count toward the 2?Do FET cycles count toward the 2?– When does the clock start ticking (what constitutes When does the clock start ticking (what constitutes

one cycle)?one cycle)?» Start of medsStart of meds» Completed retrievalCompleted retrieval» Completed transferCompleted transfer


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

Do I have infertility benefitsDo I have infertility benefits Do I need a referral?Do I need a referral? What is my co-pay for a specialist office visit?What is my co-pay for a specialist office visit? Effective date of my policyEffective date of my policy Renewal date of my policyRenewal date of my policy Is there a deductible or co-insurance?Is there a deductible or co-insurance?


Questions about blood workQuestions about blood work

Is diagnostic blood work covered?Is diagnostic blood work covered? Estradiol, FSH, LH, Hep B&C, HIVEstradiol, FSH, LH, Hep B&C, HIV

Is monitoring blood work covered?Is monitoring blood work covered? Estradiol, FSH, LH, ProgesteroneEstradiol, FSH, LH, Progesterone

Is blood work for genetic testing covered?Is blood work for genetic testing covered? Chromosomes; Cystic Fibrosis, Tay SachsChromosomes; Cystic Fibrosis, Tay Sachs

Am I required to use specific labs?Am I required to use specific labs?


Questions about diagnostic testing proceduresQuestions about diagnostic testing procedures

Will my new patient visit be covered?Will my new patient visit be covered? Will any of the following be covered?:Will any of the following be covered?:

Semen analysisSemen analysis Hysterosalpingogram or SonohysterogramHysterosalpingogram or Sonohysterogram Endometrial biopsyEndometrial biopsy Transvaginal ultrasoundsTransvaginal ultrasounds

– DiagnosticDiagnostic– Monitoring as part of cycleMonitoring as part of cycle


Questions about IUI treatmentQuestions about IUI treatment

Do I have coverage for intrauterine inseminations aka Do I have coverage for intrauterine inseminations aka artificial inseminations?artificial inseminations?

Is prior authorization required?Is prior authorization required? Is there:Is there:

A maximum number of cycles? Does the maximum include A maximum number of cycles? Does the maximum include all treatment cycles?all treatment cycles?

A dollar amount maximum?A dollar amount maximum? Coverage for sperm washing?Coverage for sperm washing?


Questions about IVF TreatmentQuestions about IVF Treatment

Do I have coverage for In Vitro Fertilization?Do I have coverage for In Vitro Fertilization?

Is prior authorization required?Is prior authorization required?

Is there:Is there: A maximum number of cycles? Does this maximum A maximum number of cycles? Does this maximum

include all treatment cycles?include all treatment cycles? A dollar amount maximum per year or lifetime?A dollar amount maximum per year or lifetime?


Questions about Embryology Lab ProceduresQuestions about Embryology Lab Procedures

Is there coverage for Intracytoplasmic Sperm Injection Is there coverage for Intracytoplasmic Sperm Injection (ICSI)? CPT codes 89280 or 89281(ICSI)? CPT codes 89280 or 89281

Is there coverage for Assisted Hatching? Is there coverage for Assisted Hatching?

CPT code 89253CPT code 89253 Is there coverage for Cryopreservation of embryo(s)? Is there coverage for Cryopreservation of embryo(s)?

CPT code 89258CPT code 89258 Is there coverage for Cryopreservation of sperm? Is there coverage for Cryopreservation of sperm?

CPT code 89259CPT code 89259


Questions about MedicationsQuestions about Medications

Do I have a separate pharmacy carrier?Do I have a separate pharmacy carrier? Do I have coverage for oral medications (ie, clomid)?Do I have coverage for oral medications (ie, clomid)? Do I have coverage for injectible medications?Do I have coverage for injectible medications?

Bravelle, Follistim, Gonal FBravelle, Follistim, Gonal F

Is prior authorization required for my medications?Is prior authorization required for my medications? Do I need to utilize a specific pharmacy?Do I need to utilize a specific pharmacy?


In ClosingIn Closing

If unable to access this information from your insurance If unable to access this information from your insurance company contact your benefits administrator thru your company contact your benefits administrator thru your employeremployer

Don’t take “no” for an answer or a first response as the final Don’t take “no” for an answer or a first response as the final word. Request to speak to a supervisorword. Request to speak to a supervisor

Your doctors office has experienced people to help you Your doctors office has experienced people to help you obtain information and help you understand it. However, obtain information and help you understand it. However, ultimately we cannot guarantee benefits. Benefits are ultimately we cannot guarantee benefits. Benefits are between patients and their insurance company.between patients and their insurance company.


Questions and AnswersQuestions and Answers

Thank you!Thank you!

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