Know your rights: The Montana Fertility Coverage Mandate

By |2018-04-09T15:40:48+00:00March 20th, 2018|Categories: Support|Tags: , , , |Comments Off on Know your rights: The Montana Fertility Coverage Mandate

The Montana infertility mandate, enacted in 1987, requires HMOs to provide coverage for “infertility services” as a basic health care service that must be covered but it doesn’t define infertility or which services must be covered. Further information is clarified in Section 33-31-102 of the Montana Code Annotated which last updated in 1996. A summary of eligibility requirements, exemptions and services covered is outlined below.

How the mandate defines infertility

This law doesn’t provide a specific definition for infertility. The most widely recognized definition of infertility is “Inability to conceive after 12 months of unprotected sexual intercourse.”

Eligibility requirements

Patient requirements: There are no patient requirements defined by the law. Coverage would likely

Insurance Requirements: The law only extends to HMO plans and does not require coverage of infertility services for other types of insurance plans.

How the law treats male infertility

The law does not distinguish between male and female infertility.

Services that are covered

The law does not specify which diagnostic tests, medications, services or procedures would be covered. This would likely vary by insurance provider. Most providers have a statement about what they cover.

Exemptions

Under this mandate, non-HMO plans (like PPOs, high deductible plans, etc) are not required to provide coverage and are explicitly exempt from from providing coverage for reversal of sterilization, artificial insemination, or treatment for infertility.

Tips & Resources

Having a law in place goes a long way to help ensure that you can access treatment should you need it but navigating insurance can be tricky and dedicating a little bit of time to understanding your benefits and your options can help you make a plan that you and your partner feel good about.

Get to know your insurance plan: Because the mandate only extends to HMO plans, it is a good idea to know what they are and find out if your employer offers them. If you haven’t had to use your health benefits before, here’s a nice primer article to give you an overview of how health insurance works and how to figure out what your out-of-pocket costs are likely to be.  You should also look up your insurance provider’s statement on fertility services. Because the law is ill defined, each provider is likely to define services differently and ave different requirements. Generally, HMO’s follow medical guidelines and will require people to try least expensive and invasive treatment options before authorizing higher cost procedures. Getting an understanding of how your insurance treats fertility problems can help you know what your options are and help you better communicate with your doctor.

Take advantage of other health benefits you may have: such as HSA/FSA accounts, preventative health services and wellness programs offered through your insurance. Getting healthy as possible can improve the health of your unborn child and potentially improve your chances of conceiving (naturally or with treatment).

Additional Resources: There are several organizations that support people who have trouble getting pregnant including Fertility within Reach (focused on helping people navigate insurance issues) and Resolve (that does both advocacy and peer-led patient support groups). You may also be able to connect with other people in your area via our local forum boards.

References:


Sara SDx

Sara SDx

Editor of Don't Cook your Balls, Co-Founder of TrakFertility.com, Health Coach and Men's Health Advocate. Passionate about sperm, men's health and helping people build their families.
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