Does health insurance cover tubal ligation reversal? It could if you have a medically necessary reason. If not, understand the alternatives.
Some site visitors may find that their plan covers a viable option instead!
Insurance is a confusing and complex topic. Many site visitors begin by asking the wrong questions. The industry works much differently than most people think. Get straight answers to the most common topics of interest.
- Coverage of elective vs medically necessary reversals
- Does plan design make a difference?
- Do certain companies provide different benefits?
Health Insurance Tubal Ligation Reversal Coverage
Follow the money and regulations to understand health insurance and tubal ligation reversal surgery coverage. Economics plays an important role, as does the regulatory environment. The carriers play by both sets of rules.
Your outcome depends on whether you want, or need the procedure. Your alternative course of action depends on laws in your state.
You will not find health insurance coverage for an elective tubal ligation reversal. The same holds true for an Essure coil removal. The surgery is elective if you changed your mind, and you want to restore your fertility.
The carrier does not want to pay claims just so that you can have another baby. The cost of prenatal care, labor, and delivery are extremely high.
Financing programs are a better alternative for elective procedures. Get your treatments started right away without the frustration of searching for something that does not exist.
You may find health insurance coverage for a medically necessary tubal ligation reversal. The procedure is medically necessary if it prevents, diagnoses, or treats an injury, disease, or symptoms.
The carrier may classify the surgery as medically necessary if you suffer from Post Tubal Ligation Syndrome (PTLS). Your surgeon might have injured other organs. Changes in blood flows can trigger associated diseases and symptoms.
Work with your gynecologist to develop a claims narrative and present the narrative to your carrier for precertification.
State infertility mandates do not require tubal ligation reversal health insurance coverage. However, they sometimes require coverage for portions of your primary alternative – In Vitro Fertilization (IVF).
Fifteen states have infertility mandates. Every single one specifically excludes coverage for the reversal of a voluntary sterilization. Nine require IVF coverage. If your employer situates its headquarters in a mandate state, you may find help with these costs.
Health Insurance Plans Covering Tubal Ligation Reversal
Do not waste your time looking for health insurance plans to cover tubal ligation reversal surgery. The plan design has nothing to do with what they cover. They determine how you access care, how they reimburse providers, and what amounts the member must fund themselves.
Financial assistance and government grants often prove more helpful.
Health Maintenance Organizations
A Health Maintenance Organization (HMO) is a closed insurance plan. The plan pays participating providers a fixed monthly fee, and they agree to treat the membership population. HMO’s follow the same rules for medically necessary and elective tubal reversals. Some infertility mandates (Ohio) apply only to HMO’s.
Preferred Provider Organizations
A Preferred Provider Organization (PPO) is an open health insurance plan. The plan reimburses participating providers for each service according to a pre-negotiated fee schedule. A PPO works no differently for necessary and elective tubal reversals. PPO’s also must comply with any applicable infertility mandate.
Supplemental health insurance plans do not cover tubal reversal directly. However, they do cover your intended result. When you become pregnant your medical costs will rise, and your income often falls. Your primary plan often leaves you with copayments and deductibles. Your employer probably does not provide paid maternity leave.
Short-term disability plans replace a portion of your income while you are unable to work due to pregnancy complications, and after your labor and delivery. Hospital indemnity plans make additional payments when you check into the hospital for normal childbirth.
Insurance Companies Covering Tubal Ligation Reversal
Public and Private health insurance companies may cover tubal ligation reversal surgery when medically necessary, but not when deemed an elective procedure. However, the similarities end there. Mandates exempt public companies from compliance in most cases. This could affect your choices for alternative and subsequent treatments.
Tubal reversal cost figures may help you with budgeting.
Public health care programs follow standard guidelines for tubal ligation reversal coverage. However, each entity has differing sets of regulatory bodies governing their operations. This may affect your outcome.
Medicaid is a public health care program for certain low-income citizens. Medicaid may cover medically necessary tubal reversals, but not elective procedures, including other treatments intended to restore fertility. The federal government establishes broad rules and provides funding to the states.
Each individual state has varying Medicaid eligibility requirements. Those expanding access under the Affordable Care Act have an income limit of 138% of the federal poverty level. Those not expanding have lower limits. Most expand income eligibility for pregnant women. Sometimes the programs operate under different names.
|State||Medicaid Name||Expansion Status|
|New York||NYS Medicaid||Yes|
|New Jersey||NJ Family Care||Yes|
|North Carolina||Health Choice||No|
Medicare is a public healthcare program for citizens over the age of 65, those with end-stage renal disease, those who have received Social Security Disability Income for 24 months, and those with Lou Gehrig’s disease. The target population is unlikely to care whether Medicare covers getting your tubes untied.
Tricare is a public health care program serving uniformed service members, retirees, and their families. Tricare may address certain reproductive services for members wounded on active duty. Tricare excludes elective tube untying on its website documentation.
Private health insurance companies may cover tubal ligation reversal when medically necessary, but not when deemed an elective procedure. You will see little variation based on the name of the organization. The rules of economics apply equally.
Private companies are far more likely to be subject to infertility mandates. This means that they may have no choice but to pay for portions of your best alternative for treatment – IVF.
Blue Cross Blue Shield
Blue Cross Blue Shield Association (BCBS) is a national federation of thirty-seven independently owned and operated insurance companies. Each affiliate makes its own business decisions and operates in states with different regulatory environments.
BCBS covers having tubal reversal following the same rules already noted. Some blues may pay for a portion of IVF treatment – if subject to a mandate. They sometimes use trade names.
|Pennsylvania||Capital & Highmark||No||No|
Other large private insurance companies may cover getting your tubes unclamped using the same logic already noted. You will find little variation based on the name of the company. Market forces do not vary by company name.
However, regulatory environments vary by state of issue. A mandate may apply, forcing the company to pay for a portion of your IVF.
- The Aetna Company operates in fifty states. Aetna is subject to an infertility mandate in some. Aetna excludes benefits when either partner has had a previous voluntary sterilization.
- Cigna is a global company based in Connecticut. They operate in many different regions. The Cigna website describes the process but does not indicate that they cover the procedure – as expected.
- Kaiser Permanente is a not-for-profit healthcare company operating in California. California has an infertility mandate in the group marketplace.
- United Health Care (UHC) is an operating division of UnitedHealth Group, the largest single carrier in the USA. UHC covers infertility services when they must comply with a local coverage determination. However, across the board, they do not cover elective procedures.
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