Melanie Cole (Host): When a patient or couple is considering using assisted reproduction technologies to have a baby, there are many things to consider. In addition to the physical, mental and emotional aspect surrounding fertility treatment, there's the financial aspect to consider. My guest today is Dr. William Ziegler. He's a board certified specialist in reproductive endocrinology and infertility at the Reproductive Science Center of New Jersey. Welcome to the show, Dr. Ziegler. Tell us about fertility treatments and insurance. Is there insurance that pays for these treatments?

Dr. William Ziegler (Guest): There are specific plans. But, as you take a step back, I just want to go through a little bit about that. There is approximately 7.3 million Americans who have a diagnosis of infertility, and that works out to be one in eight couples. And, when you have a diagnosis of infertility, it's not viewed the same way as with diabetes or heart disease. So, plans don't always cover infertility treatment. There are several different plans out there which are the public insurance and the private insurances, but they very markedly with regard to coverage. In the last few years, more states are developing plans to cover infertility treatment. At this point, there are 15 states that have coverage or offer coverage for infertility diagnosis and treatment. However, the plans are markedly different amongst the companies.

Melanie: Is New Jersey one of those 15 States?

Dr. Ziegler: Yes, it is. Back in 2001, the mandate was passed within the state of New Jersey that basically requires an insurance company to cover fertility treatment. However, even though there is the mandate in our state, there are loopholes. Some of those loopholes are that the employer has to have at least 50 people that are part of the company and part of the plan, so it can keep the premiums lower. Also, a couple needs to attempt conception without protection for at least two years if they’re under the age of 35. If they're over the age of 35, they have to be trying for at least a year.

Melanie: So, if they work for a company that's less than 50 employees, the laws mandating the coverage for IVF does not apply to them. If they work for a bigger company, then what are their plans just generally like to cover IVF?

Dr. Ziegler: Usually, if it’s under the mandate, they have unlimited intrauterine insemination coverage for treatment. The have all the diagnostic testing that is covered and they are covered for four IVF cycles per lifetime.

Melanie: What about medications, fertility medications that you're giving people? Are those covered?

Dr. Ziegler: If they cover the procedure, yes, they cover the medication.

Melanie: So, what do you tell people when they ask you questions about maneuvering this maze of insurance?

Dr. Ziegler: It really comes down to what does their policy actually state because in the mandate, it doesn't state that you have to fulfill any prerequisites. So, when we look at somebody's insurance or when we ask the patient to look at their insurance with regard to coverage, we want to know the limits of their coverage. In some cases, they're given a certain amount of money to cover fertility treatments. Especially in those plans that are personal plans instead of group plans, they have basically a maximum amount of money that a couple can use for fertility treatment. We also need for them to look at their deductible because even though a physician is in-network, they could have a substantial in-network deductible that they need to meet before the insurance will start to pay their medical bill. We also take a look at co-payments. Again, a big thing is the pre-qualification requirements. There are some insurance companies that mandate a couple to do several insemination cycles before they go on for in vitro fertilization despite what the underlying diagnosis is.

Melanie: What about some of the other things you and I have discussed before, like egg donation and that sort of thing? Are those also included?

Dr. Ziegler: They are in specific plans. With the mandate, with the four IVF cycles that are covered, usually one of them can be converted to a donor egg cycle. However, keep in mind that with the donor egg cycle if you're doing a fresh cycle, they're not going to pay for the donor’s compensation for undergoing this process. They're not going to pay for any travel expenses, food or lodging having to do with the donor, only the medical aspect of the treatment.

Melanie: And do they consider tubal ligation reversal part of that fertility treatment?

Dr. Ziegler: No, they do not. Once a woman has had tubal ligation or if a man has had a vasectomy, fertility treatment at that point in time has gone out of the window for them. The only situation is if we do a tubal reversal and the tubes are now open, in some cases, then they would fall back under their infertility coverage, because their tubes are open and they should be functional. The same thing with a man having a vasectomy, if he has a vasectomy reversal and he has a semen analysis which is now normal, then the insurance companies may take that as he is now normal or her tubes are now open and now their policy is back activated again.

Melanie: And does COBRA cover fertility treatments as well?

Dr. Ziegler: It does, depending on what the plan is. If you are leaving a company and you have infertility coverage with that company under that plan if you leave you can COBRA that policy to cover fertility treatment.

Melanie: And, what about Medicaid?

Dr. Ziegler: There is no coverage for fertility treatment and those under a Medicaid policy. Back when the Affordable Care Act was discussed, a lot of individuals thought that infertility was going to be part of the coverage with the Affordable Care Act and, in reality, it is not.

Melanie: Wrap it us for us, Dr. Ziegler, with insurance and affording fertility treatments, and what do you tell patients every day if they question you about insurance or if they have to worry about out-of-pocket expenses and co-pays and possibly paying for this themselves?

Dr. Ziegler: What we normally do is, we will go through a patient’s policy before they even set foot in our office, and we give them a phone call and give them the expectations of what their policy actually covers because many patients do not understand the insurance coverage. every policy is different, so we have to actually educate our patients. For those that are self-pay, we do go through what the costs are for a specific treatment cycles. We do have plans in place to help offset that cost. With regard to the insurance itself, we have to really take a look at their policy and, in many cases, have to call the insurance company directly because the policies are very vague when it comes to fertility treatment and what it exactly covers. So, even though reproduction is part of a couple’s normal life cycle and, in reality, if somebody does have infertility, it should really be deemed as disability and should be covered by insurance plans, but it's not viewed the same way. Also, the couples themselves are viewed differently. Within our society now, we have same-sex relationships and they want to get pregnant. Well, in many cases, they don't have coverage because, according to the mandate, a woman has to try to conceive for either two years or a year prior to any infertility coverage being activated. In a lesbian couple, in many cases, that is not the case. However, if you have a heterosexual couple and he is azoospermic, or doesn't have any sperm, they fall under fertility coverage, even though she was not exposed to sperm for two years or a year. So, there is some discrimination between couples and our social climate.

Melanie: What a fascinating topic, Dr. Ziegler. Thank you for covering this topic so clearly and explaining it to us today. You're listening to Fertility Talk with RSC NJ. For more information you can go to www.fertilitynj.com. That’s www.fertilitynj.com. This is Melanie Cole. Thanks so much for listening.