While health insurance plans in general contract to pay a sum of money to the insured in the event of a medical claim in return for the payment of premiums, consumers find many variations. Some health plans force patients to pay large deductibles or limit benefits. Other plans give excellent coverage and require little out-of-pocket expense. As a consumer, you need to understand the type of insurance coverage you currently possess. Do you have a 1) traditional insurance plan, 2) managed care plan, or 3) self-insured plan?

Traditional Insurance—If you have traditional insurance, the insurance company writes a contract and reimburses medical claims with the premiums they collect from policyholders like you. The insurance company makes a profit by restricting benefit coverage. If the contract excludes infertility treatments, you will not be covered. In traditional coverage, the insurance company assumes all risk for a specific number of illnesses and hopes premiums will exceed claims so they experience a profit. If claims exceed premiums, the insurance company suffers a loss.

Managed Care Insurance—If you have a managed care plan, your primary care physician manages your care. You consult with your primary care physician for all medical problems and the primary care physician makes referrals to specialists, hospitals, and other healthcare facilities as necessary. If you proceed directly to a specialist without a referral, your claim will be denied. Primary care physicians, often called gatekeepers, can save insurers money and lower your premiums because they control the flow of your health care. However, infertility patients may find that they cannot get past the gatekeeper to see the specialist for the treatment they need.

Self-Insured Groups—Most large employers self-insure their health insurance benefits. If your employer has assumed the role of an insurance company and collects premiums from employees, reimburses medical expenses, and determines benefits, you belong to a self-insured group. Typically, the employer hires an insurance company to administer payment of benefits and deal with claims processing, medical review, and other related insurance functions. Some employers perform claims processing themselves to eliminate the cost of the insurance administration. As a group, the employer may offer both traditional and managed care plans to their employees. Self-insured groups have the latitude to amend or change their current benefits as they desire because they are paying the premiums. If group members can convince the employer to expand infertility coverage, self-insured members will not run into barriers similar to those found in traditional insurance and managed care plans.

You may live in one of the 13 states that provide mandates for infertility services. Mandated benefits vary by state. An actual mandate requires insurers to provide infertility coverage, but some states only have a "mandate to offer." A mandate to offer requires insurers to offer coverage, which employers may or may not choose to purchase. Mandated coverage may also depend upon the relationship between you and the insurance carrier. Mandates usually target traditional health insurance companies.

Occasionally, mandates also cover managed care plans that are doing business within a given state. However, federal ERISA (Employee Retirement Income Security Act) laws exempt self-insured groups from state mandates. As more and more employers choose to become self-insured, fewer people will have infertility coverage from mandates.

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