Health insurance and Hospital Surgery care

Some of the health insurance plans that cover infertility consider infertility a catastrophic event that affects worker productivity. Some plans that don’t cover infertility may pay for infertility treatments that are permissible under other covered benefits, such as pelvic surgeries.

Unless your insurance plan contract specifically excludes infertility, you should be covered. If your contract does have an exclusion, read the contract carefully to understand what, specifically, is excluded.

Under the Americans with Disabilities Act (ADA), employers must treat persons with disabilities the same as they treat other employees with respect to the terms and conditions of employment, including fringe benefits such as health insurance coverage. The United States Supreme Court ruled that reproduction is a major life activity under the ADA. Therefore, infertility is a disability.

Title VII of the Civil Rights Act of 1964, as amended by the Pregnancy Discrimination Act (PDA), affirms that discrimination based on pregnancy, childbirth, or related medical conditions is considered sex discrimination. Because infertility is regarded as a medical condition related to pregnancy, employers must provide you with the same benefits such as insurance and time off from work as their other employees.

Medical Tests and X Rays

Some health insurance plans pay 100 percent of covered charges for routine and diagnostic medical tests and X rays, up to an annual dollar limit. For example, the plan may pay the first $100, after which you pay a deductible and coinsurance. With other plans, you may have to pay first: You pay the deductible and coinsurance, and then the plan pays 80 percent (for an in-network provider) or 50 percent (for an out-of-network provider) of the covered charges.

Comparing Accidents to Illnesses

If you run a high fever or fall out of a tree, you may visit a hospital emergency room. Both of these conditions is an “emergency” to your mind, and accordingly, you expect your health insurance plan to cover the associated charges, according to the schedule of benefits, a table or list showing the maximum amounts a plan pays for covered expenses. However, some plans may pay one benefit for visits to the emergency room for an illness, such as a fever, and another benefit for an accident, such as falling from a tree. Other plans pay the same regardless of the reason for the visit. Make sure that you clearly understand what your plan pays for a visit to the emergency room, whether for an illness or for an accident. Also check whether the plan requires notice before you visit the emergency room and, if so, what the penalty is for not giving notice.

Hospital Care

health insurance plans may impose a deductible and coinsurance or a daily copayment amount for hospital coverage. In either case, the plans usually limit coverage to the rate for a semi-private hospital room, as defined in the insurance policy. Payment may differ based on whether the hospital is in a plan’s network. Check your hospital bill carefully: Mistakes are common. Make sure you actually received each service the bill lists.

Surgery (Inpatient and Outpatient)

The insurance industry defines surgery as

- A treatment that breaks the skin

- An examination that uses a scope that goes farther than the normal body opening

- Burn treatment

- Tissue removal

- Treatment of open and closed fractures

Coverage for surgeons’ fees for surgical procedures may vary depending on whether the provider is in-network. These rates also apply to surgery-related services, such as anesthesiology, pathology, and radiology. Find out ahead of time whether both the surgeon and the hospital are members of the plan network. Some plans pay 100 percent of fees for outpatient surgery, which is probably less expensive than inpatient surgery because you spend your recovery period at home instead of in the hospital.

You may pay a penalty if you don’t get certification (advance authorization) before you enter the hospital or before you undergo outpatient surgery. Check your plan’s provisions. Insurers usually base their coverage on reasonable and customary fees for surgical procedures.

Pre-Existing Conditions

The term pre-existing condition used to refer to a health condition that was diagnosed or treated during a certain time before the date an insurance policy took effect, or for which a prudent person would have sought treatment. This definition gave insurers a fair amount of leeway in imposing exclusions and waiting periods for pre-existing conditions. The definition of “pre-existing condition” and regulations based on that definition changed with the health insurance Portability and Accountability Act (HIPAA). This section explains how HIPAA may benefit insured persons who have pre-existing conditions. Individual states may set their own, stricter obligations on insurers in certain areas, such as shortening the maximum waiting periods and requiring special enrollment periods. Check with your state’s insurance department for these changes. (To find information on your state insurance department, contact the National Association of Insurance Commissioners, listed in the Resource Center.)