Massachusetts fertility coverage FAIL. Now what?

[CassnBeth]

Oh for the love of....someone!

I live in Massachusetts where infertility is covered -- one of the few states! -- and yet I can't get any of my treatment covered because they won't take my word for it on having exposure to sperm!! Apparently a straight couple only has to say they have been trying to conceive for 12 months in order to make the insurance pay for treatment but a lesbian couple has to have done all their insems in a doctor's office or they don't count! And I already have a diagnosis of PCOS and definitely am not ovulating so I can certainly prove infertility!

What on earth do we do now? Has anyone else dealt with this? How bad is this going to be? We have Blue Cross/HMO Blue if that means anything. When I call the insurance company they say that all I need to do is get this form filled out stating that I am infertile but Boston IVF says, in their experience, coverage just keeps getting denied. HUMBUG

[osker]

You might try with Reproductive Science Center in Lexington, they seemed to me to be more lesbian friendly. We toured their facility but didn't end up going that route (preferred to stay at home).

Will they let you show receipts from the purchase of sperm over 12 months as "evidence"?

What's your age? You may only have to do 6 IUIs in the office depending on that. I know it seems easier to skip right to IVF, but wouldn't it be nice if you could get pregnant with less intervention? We thought about skipping to IVF but ended up getting pregnant at home, just us... we have friends who have been through IVF countless times over several years and are still not pregnant. It's nice to think it would be the answer, and I'm not saying you're thinking this way, but sometimes it isn't..

[CassnBeth]

I don't have receipts! Our daughter was conceived using home insems for my wife who could get pregnant from a rock. And DW and I are only 28 so well under the age limits

We didn't choose Boston IVF with IVF specifically in mind. In fact, I really only think IUIs and meds will be necessary but I wanted a practice with a lot of experience handling infertility. I'm sure we'll be doing some home insems during this attempt (thank you in home known donor!) but without any monitoring or meds at all we might as well not bother. I can go six months without a period easily.

[osker]

Another thought, are you legally married? Can you go in single? I have no idea if that would make a difference... if you're doing known donor can you and your "boyfriend" go in and say you've been trying for a year?
I know that we couldn't go in as anything but who we are, but we tend to be more prudish than most!

[megincl]

We used BIVF (and love them, by the way).

I think that the requirement to document your tries is rather firm, but it's really important to have a doc who will consider other reasons for you not getting pregnant. This may then help with the documentation issue. For instance, we had only 2 documented tries with a doc as we also used KD sperm. But, we had 4 early losses. That actually qualified us for IVF, mostly so that the embryos could be tested for the most common chromosomal abnormalities that cause early miscarriage. So you need someone who thinks outside the box a bit, not just "document 12 tries, then we'll see what's next." We used Dr. Ryley, who I think is really good at that kind of thinking...could be worth trying to see him, though of course there's no guarantee.

It also, though, sounds like you really want to work on triggering ovulation, so your focus might have to be slightly different than just infertility, if that makes sense. I'm in a bit of a newborn haze, so not sure it does...

Best of luck figuring this out.

[FtMPapa]

It's blatant discrimination and it's totally bogus.

Talk to the folks at the insurance company, file appeals, and fight it, it my advice. I've been there, done that, though with a different company and for different reasons, but I was told the exact same thing by a different fertility clinic.

Were you ever married to a male? That might be a loophole, if you were, you can say you were infertile then. (That one is a bit stickier, but it worked for someone I know.)

The legal definition of infertility does not require intercourse - it requires twelve months of attempts to conceive. If you were using a known donor at home, that should count.

Also, go in with the donor as your partner...BIVF really won't ask too many questions or look too hard if that's your story and you stick to it.

[CassnBeth]

I'm out of luck on casual lying. My wife and I are legally married and my insurance is through her so it's very obvious. And I've never been married to anyone else.

Thanks for all the brainstorming, I appreciate it. I'm especially glad for the vote of confidence for Dr Ryley who is the guy I'm supposed to be seeing. Ridiculously, my PCOS diagnosis will happily cover seeing all sorts of OBs and REs and preconception bloodwork and HSGs and even femara to cause me to ovulate BUT NOTHING ELSE. Including monitoring to see if the femara worked. FtMPapa, can I ask without being too nosy, how did you go about fighting the insurance on this?

This whole thing makes no sense and I really was not expecting to feel this angry and betrayed at this stage of the process. We spent a year and a half trying for our daughter and I had three miscarriages and it still took close to nine months to feel this mad.

[sunwillshine]

I unfortunately don't have any advice or ideas, but I couldn't read and not offer s.

And, with re: to the "casual lying" in order to get treatment, we were encouraged (!) by a fertility clinic to do this when we first thought doctor-performed insems were the way to go, because they had all kinds of rules about quarantined sperm and wouldn't use freshies if the donor wasn't your "intimate partner" etc...

... and TBH, my (very) humble (and personal) opinion is that I could not have dealt with conceiving this child based on a lie. I ESPECIALLY did not want to have it anywhere on any record that our KD was my "intimate partner" since that could just further complicate things legally when we went to do the second-parent adoption and have him terminate his rights.

I want to make clear I am NOT judging anyone who does make that decision, just that we couldn't go through with it for various reasons.

CassnBeth, I wish you all the best, and hope you find some way around and through these hoops you're facing. There's so many ways to create a family, and I hope you're able to find the best (most affordable!) way for you and your wife!

[Magistra]

Are the 3 earlier miscarriages documented? I had 2 at over 30, so that would have qualified me for the infertility clause in my insurance (not in Massachusetts, though), but one of them was undocumented, thanks to the health care system in Ontario (couldn't get in to see a doc or midwife before the miscarriage and then my paperwork for the ultrasound disappeared entirely). Our insurance wouldn't even consider my case without the paperwork.

[megincl]

For meeting Dr. Ryley, I would just tell him as MUCH as possible. He definitely wants to help folks get pregnant and wants to find the way, but he's definitely bound by the insurance folks who tell him what he can and can't do. I'd say, though, that he's good at trying to find the right scenario to make it work -- so I'd really be as detailed and as looking-at-it-from-many-angles as you can!

[CassnBeth]

No, the miscarriages are not documented. One was when I was 20 and I had the misguided thought that it would somehow be less painful if I never had confirmation of the pregnancy. The other two were while we were trying for DD and I didn't have health insurance. Since I was already on progesterone supplementation my awful but affordable GP said there wasn't much else to be done if I started bleeding and just to let it take its course.

[gellybeangrl]

Hi CassnBeth,

I completly understand your frustration. I live in Illinois, we also have a state infertility law...but ours states that, "Infertility means the inability to conceive after one year of unprotected sexual intercourse or the inability to sustain a successful pregnancy. Unprotected Sexual Intercourse means sexual union between a male and a female, without the use of any process, device or method that prevents conception, including but not limited to oral contraceptives, chemicals, physical or barrier contraceptives, natural abstinence or voluntary permanent surgical procedures."

My partner and I have been ttc for 7 months now with no sucess. I have other medical diagnoses (PCOS, Ovarian Cysts, insulin resistance ) that lead my OBYN and RE to believe that I will not be able to get pregnant without medical intervention. Anyway...

I called my insurance company a few days ago to find out about what they covered for infertility only to be told that since I had not been having unprotected sex with a man that I could never get help for infertility and that even though we have done 5 IUI's they don't count...because I've not had unprotected sex with a man. ARE YOU KIDDING ME?!?!?

I too had the idea of just going in with a good friend of ours and telling them that we were a couple in order to get some help with infertility treatments. We're not sure what we are going to do. I'm really frustrated, angry and generally pissed off about the whole thing.

[mumm]

Trying to get this straight, because once we started in getting medical help in MA it was all very easy and cheap.

You've been doing home ICIs with KD with no luck? Your insurance is through a MA based insurance company? If I've got that right can't you pay for 3 cycles of an office based ICI/IUI to show it isn't working? I think then you'd have to pay for another 3 medicated cycles before the manated IVF coverage kicks in. Honestly, you don't want to get to the point of needing IVF since that is really a whole different ball game of ttc.

When it was clear for us that ttc at home wasn't going to work we hooked up with a RE not affiliated with a clinic. Worked for us on our first clomid cycle. With kid two we did a clomid cycle again. When we began ttc kid #3 it felt different since we both assumed clomid would do the trick. It didn't and then we started down the path of medicalized conception. We did 3 clomid and 3 injectable cycles before then switching to IVF via a MA based insurance company. I called the two largest insurers and talked to a nurse and told him the truth about the situation, history of all conceptions, etc. Then I waited to see if I would be accepted as infertile before evening buying the insurance oop for the month/s I would need it. It was all medical history stuff and had nothing to do with WHOM or HOW the sperm was getting there. (or not getting there!) I found the insurance co (Pilgrim) to be excellent and helpful. And a monthly payment that was much less than a medicated iui cycle for IVF.

Have you called the Resolve helpline for information. They were great when I was looking into buying insurance in MA for the IVF cycle.

And to keep you positive about more than just logistics and finances, kid #3 (and 4!) arrived from an IVF cycle. Be careful what you ask for!

[megincl]

I think that now pretty much all insurance companies in MA require 12 doc assisted cycles before moving on to IVF. When we began IVF, Harvard Pilgrim had just switched from 6 to 12. But check check check!!!

[FtMPapa]

I don't see it as lying to say that your KD is your intimate partner.

There are two reasons to frame your relationship that way:

1. The clinics generally use stricter rules than the FDA requires. The FDA does not provide a definition for their term "sexually intimate partner." Medically, in terms of risks of STDs, a KD should be considered the same. So in my book, it's not lying when you are given a heterocentric lack of definition and apply it to your situation. I was upfront about most things - the cinic knew we had separate insurance, addresses, and telephone numbers. I actually didn't lie about anything, I just let them assume.

2. The insurance companies are discriminating against queers. Straight people do not have to prove they've been having unprotected intercourse. I know straight people who had birth control scripts, tried for 6 months post-BCP, didn't get preggers, lied to the insurance about trying for a year, and nobody ever checked her health records. If they had, obviously they would have seen a BCP script six months ago.

On the flip side, queers have to prove what they've been up to, and have to have licensed medical providers perform it.

Also, straights - one year of trying. Queers - 12 cycles of doctor assisted IUI. For those who aren't even ovulating, or who have longer cycles (common with annovulatory cycles), that takes longer than a year. Also, the cost, given that many of us are using donor sperm, plus the cost of the IUI, a typical cycle can easily cost $1,000. And that's unmedicated, unmonitored.

Last, the insurance company's rules are bogus. You shouldn't have to wait a year to have coverage when you have a pre-existing diagnosis.


So, back to the original question - how do you fight with your insurance about it?

You threaten to sue them. You find a lawyer, you point out that you know the law and the law does not require intercourse, and that their actions could be seen as discriminatory since they have different requirements and impacts on straights and queers.

NB: It is legal to discriminate in the US and in MA on the basis of marital status, so tread carefully there.

The insurance company does not want a lawsuit, because they would lose. various queer community legal services MIGHT be able to help you.

It's not easy. You have to fight. And you can't talk to the person who answers the phone, you have to get a claims supervisor, likely someone in their infertility working group who actually understands this stuff.

[CassnBeth]

Well I'm glad(?) that we're all getting screwed over together. Thanks everyone for being so generous.

Mumm -- I don't understand why three in-office cycles would cause my insurance to pay for three more monitored cycles. How does that work? I would certainly be happy if that were true. The clinic we spoke to (and the insurance agreed) is that the definition of infertility for same sex couples is 12 iui/ici cycles in a doctor's office. Before that point they won't pay for anything other than routine bloodwork and, maybe, femara; though the clinic says they can sometimes get coverage for injectables.

FtMPapa -- Can I say how thrilled I am for you that you are pregnant? You were already in the thick of TTC when we were trying for our daughter and you were such a source of inspiration for me simply by being so determined. I totally agree with you that calling our KD an "intimate partner" wouldn't count as lying so much as using insufficient terminology as well as possible. I would be all over that loophole if I weren't so obviously married already. And you're right about the lawyer too. I have an ex that works with a trans/gay legal coalition in Boston; it may be time to put out some feelers that way. I admit, I am intimidated about the money aspect of it but I should ask some real questions before I discard the possibility.

[sunwillshine]

I feel like I need to clarify why I personally didn't feel like it was okay to lie about KD and my "intimate partner status." We're in NJ and will be doing a waiver of parental rights for KD and a second-parent adoption by DP of our baby girl, and anything "on the record" that KD and I were intimate partners could really work against us were KD to do a 180° and decide he wants some sort of right to our little Cadence when she arrives and it's time to put the adoption process in motion.

Of course, we trust him and feel that there is a 0% chance of this happening (otherwise, we wouldn't have used him as our KD) but it's just one of those "you can feel totally sure about someone's intentions, but still can't control changes that happen in their heads, especially after their bio-kid arrives."

Anyway, just wanted to clear that up. I understand that we have to stretch some truths and jump through hoops quite often to create our queer families, but for me, doing anything to jeopardize soon-to-arrive DD and my DP's legal relationship would never be worth it.

[mumm]

Originally Posted by mumm

If I've got that right can't you pay for 3 cycles of an office based ICI/IUI to show it isn't working? I think then you'd have to pay for another 3 medicated cycles before the manated IVF coverage kicks in.

Originally Posted by CassnBeth

Mumm -- I don't understand why three in-office cycles would cause my insurance to pay for three more monitored cycles. How does that work? I would certainly be happy if that were true. The clinic we spoke to (and the insurance agreed) is that the definition of infertility for same sex couples is 12 iui/ici cycles in a doctor's office. Before that point they won't pay for anything other than routine bloodwork and, maybe, femara; though the clinic says they can sometimes get coverage for injectables.

.

Okay, so the quotes are backwards, but I needed to have 6 cycles to prove infertility. 3 medicated and 3 unmedicated. (We actually did 6 medicated, but only because I had two other kids, both conceived with clomid, so we started our first cycle with clomid.) Maybe I've got it wrong and it was 3 clomid cycles and 3 injectible cycles??

Have you called the resolve hotline? I'm still amazed at all the info I got from them. Things that had never been mentioned (even though I'd asked!) at my clinic. They ended up saving us my sanity, boatloads of $$ and may be one of the major factors behind why I have 4 kids instead of 2.

Things have changed drastically in the RE field in the past 10 years. When my last kids were conceived it felt very demoralizing- much like a puppy mill. I'm sad that people have to START in a system like that.

[judecorp]

Originally Posted by FtMPapa 

Were you ever married to a male? That might be a loophole, if you were, you can say you were infertile then. (That one is a bit stickier, but it worked for someone I know.)

 

Ha ha, that was me. :)

 

Honestly, when I first went to BIVF in 2006 they said the same thing to me: it will never get approved. I asked them to put it through anyway, and told them specific language I wanted them to use. In my case it was "partnered with a male for several years with no ability to conceive" or something like that and the doctor and insurance person even said "no way this will work" and let me tell you, insurance (it was BCBS at the time) covered everything. Everything except donor sperm. I think in your case if the doctor is willing to write in the records "12+ attempts to conceive unsuccessfully using donor sperm and intracervical insemination" or some crap insurance will take it.

 

Several years later I went to a different clinic (moved to the other side of the state so went through Baystate Reproductive in Springfield) and had different insurance (Health New England) and was also told "I don't think this will go through" and again was covered in entirety for what I requested (IUI with FSH).

 

Honestly I think the insurance companies just expect everyone to give up.

[osker]

"Honestly I think the insurance companies just expect everyone to give up."

Jude, I totally agree with you on this one! Not in terms of medical coverage, but I often have to ask for further mental health coverage for my clients. Insurance companies make you run through the ringer to fill out paperwork, etc., but I have found they generally approve anything. 

Also, H was getting chiropractor coverage for carpal tunnel throughout her pregnancy (it's not covered if you're not pg). When she ran out, and was no longer pg, we thought we were done. Instead, the office submitted paperwork asking for more and it was approved! No problem at all! She's currently there as we speak and E is 3mo. Since it's now a continuing coverage issue, she seems to be able to get more.

I would say ask, ask, ask again!