West Virginia Law Mandating Infertility Coverage

West Virginia infertility and IVF insurance is available to some residents. The West Virginia infertility health insurance law mandates that Health Maintenance Organizations (HMO) provide coverage for diagnosis and treatment of infertility.

If your health plan is a PPO, POS, or traditional fee for service plan you may have to pay out-of-pocket for all infertility treatments. The West Virginia mandate does not cover IVF costs. Before beginning any infertility protocol learn:

• Who is covered by the mandate
• What infertility procedures are included
• How to cut your costs covered or not

The West Virginia infertility law addresses HMO's only. If your insurance plan is considered an HMO, West Virginia's law requires your plan to cover basic preventive health services, including infertility. WV insurance code defines an HMO as a public or private organization that:

• Receives premiums for health services on a prepaid per capita basis
• Provides services through physicians who are -
  • Employees or partners of the organization, or  
  • Groups of physicians organized on a group or individual basis
• Assures the availability, accessibility, and quality of care through a clearly identifiable focal point
• Offers services through an organized delivery system where a primary care provider is designated for each subscriber

The law regulates HMO's, not employers or other types of insurance contracts. If you work for a large employer that self insures, your plan is a Preferred Provider Plan (PPO), Point of Service plan (POS), or traditional fee for service plan, chances are your infertility treatments are not covered. Also if you are enrolled in an HMO that originates in another state, the plan may not be subject to the West Virginia mandate.

The West Virginia infertility mandate contains some very vague language, making it difficult to interpret for most couples trying to conceive. The law requires an HMO to cover “cost effective preventive services” including:

• Immunizations
• Well baby care - helpful when your infertility treatments succeed
• Periodic health evaluations for adult members
• Family planning services
• Infertility services
• Children’s eye and ear examinations

The preventive services need not include all the procedures or services offered by the health services provider.

So what exactly do cost effective preventive infertility services include? It may be easier to specify what is not directly mandated: specific infertility tests, fertility drugs, ICSI, and In Vitro Fertilization (IVF). Often any underlying disease which manifests in infertility may be a covered benefit. But that is only a guess.

The only specified procedure relating to infertility is oddly a section pertaining to informed consent for abortions. The patient must be informed of any potential risks for the particular procedure that may present a “danger to subsequent pregnancies and infertility”.

Chances are high that your insurance plan does not need to comply with the West Virginia infertility law. And even if it does, the odds are good that you may still have to pay out of pocket for most of your expenses. What can be done?

Take advantage of tax deductible IVF and infertility expenses. Know how the tax laws work, and which vehicles are best for your situation. Both a Flexible Spending Account (FSA) and Schedule A can be used, but may yield very different results.

Leverage hidden advantages of IVF refund programs. In addition to getting a portion of your money back if you fail to conceive, these programs are very tax efficient, and give you insider information you can use to your advantage.

Hedge against the chance of multiple birth. Fertility drugs stimulate egg production, and embryologists often implant more than one embryo in the uterus. Multiple pregnancies are often high-risk, and result in premature birth at a much higher rate. Use supplemental insurance to cover normal pregnancy, along with complications and premature birth.

West Virginia Infertility Insurance Mandate Sources: WVC 16-21- 2, WVC 33-25A-2