By Alice Crisi
For years, California advocates have struggled to secure fertility preservation insurance coverage for cancer patients. A 2013 bill even made its way to the Governor’s desk only to be vetoed because of the one penny per member per month it would cost to implement this important insurance reform.
California only requires insurers OFFER infertility coverage as a potential benefit, but it does not include In Vitro Fertilization (IVF), nor does this mandate require employers provide infertility coverage to their employees. If you read the aforementioned sentence and thought “That sounds pointless,” then you would have the same thought as most fertility advocates.
The mandate itself set up a loophole in the system for insurers to tell enrollees diagnosed with cancer, “Infertility services are not a covered benefit and fertility preservation is an infertility service.” The bottom line is fertility preservation historically was lumped in with traditional infertility services rather than being considered a part of cancer care.
And the story is still shared over and over and over again. “I checked on your insurance and infertility/fertility preservation isn’t a covered benefit.” Some physicians preemptively tell their patients, “Insurance doesn’t cover it,” further perpetuating the idea of lack of coverage.
But that isn’t 100% true.
We now know some companies cover fertility preservation for all their employees in California. We also know from informal surveys and patient feedback that some insurers cover fertility preservation as part of the standard of care for cancer.
But, due to mistaken beliefs about coverage, many patients were not asking their physicians for help with submission of prior-authorizations for coverage of fertility preservation treatment, or not appealing when the prior-authorization is denied. Records show only one patient has ever utilized California’s Independent Medical Review (IMR) process for fertility preservation. That patient, asked the California Department of Managed HealthCare (DMHC), the agency that oversees 25 million plans in California, to overturn a decision to deny her embryo freezing procedure before breast cancer treatment.
And she won.
You got that, right?
The DMHC agreed with her, her physicians, the American Society of Reproductive Medicine, the American Medical Association, and the American Society of Clinical Society, whom all state fertility preservation is standard treatment when diagnosed with cancer during reproductive years. She, as a newly diagnosed cancer patient, was granted the right to have her insurance cover her embryo freezing procedure prior to cancer treatment.
This is a clear path forward, underutilized by patients, advocates and physician offices. Armed with this information, patients can move forward and challenge the old notions.
In fact, 60% of individuals who use the IMR process have their insurance company’s denial overturned. Once a pattern ensues, the DMHC will regulate a formal change.
Our joint goal is to work with the DMHC to write a letter informing insurance companies they need to cover fertility preservation for patients diagnosed with cancer. But, we need more complaints filed in the system before that happens. We need every patient to ask their insurer for coverage and then file a request for an IMR, if their insurance company denies the treatment.
Here’s how it works:
- Your reproductive specialist’s billing manager will request a prior-authorization from your insurance company to cover your fertility preservation procedure. (Your insurance company may say yes!)
- If your insurance company denies the prior-authorization, you then file an expedited appeal through your insurance carrier (usually an online form through your own insurance company). Request an expedited review on account of your cancer diagnosis.
- If your insurance company upholds their original denial, you may then request an expedited IMR online through the DMHC (even if your plan advises you there are multiple levels of appeals). http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForm.aspx#.VspUlfkrKc0
- DMHC is required by federal law to address your request for fertility preservation insurance coverage within 30 days, but with expedited cases to be addressed within one week.
To better be able to help patients, oncologists and reproductive professionals (along with their billing personnel) may request an educational webinar via email firstname.lastname@example.org.
A great website to help you navigate the system is http://mypatientrights.org.
Check with www.OncofertilityUniversity.org for more information.
As the de-identified IMR cases will be publicly available on the DMHC website, eventually we will be able to see the cases and assess the outcome. But, if you’re comfortable, we would really benefit from you contacting us at email@example.com to let us know how the process worked for you. It would be helpful to know if you were able to get coverage right away, through the insurer’s appeals process or the IMR process. The more people use the system, the clearer it will be to regulators there is an issue they can and should address.
We’re so close to permanently changing this story in California, let’s solve this problem this year!