How do you get your tubes untied with Medicaid? How do you get your private insurance plan or company to pay for tubal ligation reversal surgery?
Surprisingly, the answer to both of these questions is the same – it will be very hard.
Here is the bottom line. Both Medicaid and private insurance plans may pay when there is a covered medical reason for each possible step: upfront testing, the procedure itself, and any post-operative issues.
In addition, supplemental policies and state-based infertility mandates open the door for alternative approaches. These avenues could be a more affordable way to restore your fertility and have another baby – or two.
Getting Tubes Untied With Medicaid
How do you get your tubes untied with Medicaid? Medicaid is a public health insurance plan for low-income families, women, and children. The federal government provides much of the funding, and each state administers the programs and set rules for eligibility and coverage.
In general, Medicaid will not pay for tubal reversal surgery in any state unless you can cite a medically necessary reason. Therefore, getting your tubes untied with Medicaid may mean finding alternatives.
Covered Medical Reasons
Medicaid and other private insurance plans may pay for three types of covered medical reasons relating to your pending tubal reversal procedure. Each phase or category must be medically necessary. Medically necessary means that the therapy prevents, diagnoses, or treats an injury, disease, or symptoms.
You may be able to get your Medicaid or private insurance plan to cover specific tubal reversal pre-surgery testing steps. Ask your clinic to code the test for a medically necessary reason.
- Pre-operative bloodwork to spot infections (STD, HIV, or Hepatitis)
- Ultrasound and exam to visualize the health of reproductive organs
It is unlikely that your Medicaid or private insurance plan will cover the tubal reversal surgery itself as it corrects earlier voluntary sterilization. The purpose is rarely a covered medical reason – unless the procedure corrects an underlying disease or symptom.
- Post Tubal Ligation Syndrome (PTLS) is the rapid decline of estrogen/progesterone hormone levels caused by damaged blood supplies to the ovaries
- Dysmenorrhea is pain and cramping during your menstrual cycle
Also, related services rendered while under the knife might be covered. For example, removal of uterine fibroids and polyps could be medically necessary and needed to restore fertility.
It is more likely that your Medical or private insurance policy will cover any complications arising from your tubal reversal operation. The surgery is very safe. However, things can go wrong, and these complications are often a covered medical reason.
- Damage to nearby organs
- Reactions to anesthesia
Medicaid Trade Names
Getting your tubes untied with Medicaid introduces two layers of possible mix-ups – as if insurance were not confusing enough already. Many states use trade names for their Medicaid programs. This chart of state Medicaid names might clear things up a little.
|Alabama||AL Integrated Care Network|
|Arizona||AZ Healthcare Cost Containment System (AHCCCS)|
|Colorado||Health First Colorado|
|Florida||My Florida Families|
|Illinois||Illinois Family Care|
|Kentucky||Kentucky Health Choices|
|New York||NYS Medicaid|
|New Jersey||NJ Family Care|
|North Carolina||Health Choice|
|Texas||Texas Medicaid & STAR|
Also, private companies such as Aetna, Cigna, and BCBS issue plans that fit under these tradename umbrellas. For example, CareSource is a nonprofit that began as a managed health care plan serving Medicaid members in Ohio. Today, it provides programs serving other populations as well.
Get Private Insurance To Pay for Tubal Reversal
How do you get your health insurance plan to pay for tubal ligation reversal surgery? Follow the same logic as for Medicaid plans (see below) – specify the medically necessary phases of the procedure (upfront testing, PTLS or Dysmenorrhea, post-operative complications).
However, health insurance plans issued in the private marketplace offer two possible opportunities to make having a baby again more affordable.
- Supplemental policies cover the expected outcome
- Infertility mandates may include other treatment options
Supplemental health insurance covers tubal reversal outcomes – not the surgical procedure itself. Remember, the purpose of this operation is to restore your fertility and have another baby.
Therefore, you may need to take unpaid maternity leave and find yourself with leftover hospital bills after your labor and delivery.
- Request a short-term disability quote to protect your income during an extended pregnancy leave before your due date.
- Hospital indemnity insurance pays a cash benefit directly to you when you enter the hospital to deliver your baby.
Act now because you cannot purchase these two supplemental policies once you are already pregnant. These plans will not cover your pre-existing pregnancy.
Site visitors often ask whether a specific health insurance company covers tubal reversal. Each company pays for the procedure only when medically necessary – as outlined above. However, each company also operates in different geographical regions.
The plans they issue in each state may be subject to an infertility mandate. These state mandates require coverage for specified treatments (such as IVF the primary alternative) – but never tubal ligation reversal surgery.
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 acts in states with different regulatory environments.
BCBS covers having tubal reversal following the same rules already noted. Some BCBS plans may pay for a portion of IVF treatment – if subject to a mandate. Also, they sometimes use trade names.
|North Carolina||BCBS NC||No|
|Pennsylvania||Capital & Highmark||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 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.
 Aetna Medical Clinical Policy Bulletin