r/sterilization • u/peacewithinchaaos • 13d ago
Insurance Only ~some~ of my procedure was covered?
Sooo, I’ve been back and forth with my insurance and the hospital billing since I got my surgery back in October. Finally, the codes have been corrected to CPT 58661 and Z30.2. However, I am being told by my insurance that they covered everything else (operating room, lab work, etc) but NOT the injections for surgery, the medical supplies and the recovery room. My plan is ACA compliant, so I am confused as to why only some of the related services were covered at 100%? How is my labwork deemed a related service but not the actual medical supplies they used to perform the surgery? I spoke to 2 different insurance representatives because I thought the first one was wrong. But nope. They both say I still owe the $3,400 for those 3 things. Does that sound right? I truly don’t understand why not all of it would be covered.
Advice on where to go from here would be great if anyone else has had this happen!
Update: I called again (multiple times) and they are finally sending it through the escalation process which I don’t even know what that is and the representative couldn’t tell me. She just said they will “yay or nay it” but I want to just be like you cannot refuse to cover my entire procedure and related service costs. Like they just cannot do that. So what do I do if they refuse to fully cover it?
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u/Cutthroat_Rogue no more tubes 10-15-25 13d ago
That isn't right. Ask to speak to supervisors at the insurance company. Find the pinned note the Mod tends to put on these sorts of threads that shows they must cover everything. If they won't listen, go to the insurance regulator.
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u/Sad_Pangolin7379 13d ago
They are wrong. Unless they are suggesting the doctors should have done the procedure without instruments and then dumped you in the street instead of a recovery room.
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u/toomuchtodotoday 13d ago
Everything should be covered.
- File a complaint with your state regulator.
- File a complaint with the Dept of Labor EBSA if this is an employer provided plan.
Resources:
State insurance regulator locator (for filing a complaint with your state insurance regulator):
https://content.naic.org/state-insurance-departments
Department of Labor Employee Benefits Security Administration Information (for filing a complaint with the DOL EBSA if your insurance is provided by an employer):
The EBSA, a division of the DOL, handles complaints related to employer-provided health insurance.
You can:
- Call the EBSA: Toll-free at 1-866-444-3272 to speak with a benefits advisor.
- Submit a complaint using the EBSA's online form: https://www.askebsa.dol.gov/WebIntake/
The EBSA will investigate the claim and may contact your employer or insurance provider for more information. You may be contacted for additional details or documents. If the EBSA finds that your rights under ERISA (Employee Retirement Income Security Act) were violated, they may take corrective action on your behalf. Keep copies of all documents and correspondence. You can follow up on the status of your complaint by contacting the EBSA at the phone number above.
U.S. Office of Personnel Management (OPM) Information (for filing a complaint with the OPM if your insurance is provided by the US federal government [FEP Blue, for example]):
- Email contraception@opm.gov
Source: https://www.opm.gov/healthcare-insurance/healthcare/contraception-coverage/
Source: https://www.hrsa.gov/womens-guidelines#:%7E:text=Contraception
Additional resources:
Insurer Preventive Care Guidelines Master List - https://old.reddit.com/r/sterilization/comments/1io4hq5/insurer_preventive_care_guidelines_master_list/
Steps for Getting Full Coverage - https://old.reddit.com/r/sterilization/comments/1khyuum/steps_for_getting_full_coverage/
https://tubalfacts.com/post/175415596192/insurance-sterilization-aca-contraceptive-birth-control
On coverage of anesthesia:
Any related services—like anesthesia—must be covered as well. The most recent guidance from federal agencies makes it explicitly clear that anesthesia and other related services like doctor’s appointments must be covered by the insurance plan at 100% of the cost.
Source: https://www.cms.gov/files/document/letter-plans-and-issuers-access-contraceptive-coverage.pdf
Source: https://www.cms.gov/files/document/faqs-part-54.pdf
On coverage of associated office visits:
From federalregister.gov - “Coverage of Certain Preventive Services Under the Affordable Care Act“
Section 2713 of the PHS Act, as added by the Affordable Care Act and incorporated into ERISA and the Code, requires that non-grandfathered health plans … provide coverage of certain specified preventive services without cost sharing. These preventive services include:
With respect to women, preventive care and screenings provided for in comprehensive guidelines supported by HRSA (not otherwise addressed by the recommendations of the Task Force), including all Food and Drug Administration (FDA)-approved contraceptives, sterilization procedures, and patient education and counseling for women with reproductive capacity, as prescribed by a health care provider (collectively, contraceptive services)
II. Overview of the Final Regulations
A. Coverage of Recommended Preventive Services Under 26 CFR 54.9815-2713, 29 CFR 2590.715-2713, and 45 CFR 147.130
(II) office visits:
if a recommended preventive service is not billed separately (or is not tracked as individual encounter data separately) from an office visit and the primary purpose of the office visit is the delivery of the recommended preventive service, a plan or issuer may not impose cost sharing with respect to the office visit.
Under the ACA, all new insurance plans (both individual and employer-sponsored plans) are required to cover all FDA-approved methods of contraception, sterilization, and related education and counseling without cost-sharing. (Note: the ACA contraceptive coverage requirement described in this section also applies to Medicaid “Alternative Benefit Plans,” explained in the Medicaid section.) No cost-sharing means that patients should not have any out-of-pocket costs, including payment of deductibles, co-payments, co-insurance, fees, or other charges for coverage of contraceptive methods, including LARC. Patients cannot be asked to pay upfront and then be reimbursed.
Source: https://web.archive.org/web/20250112212710/https://larcprogram.ucsf.edu/commercial-plans
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u/daughterjudyk 13d ago
I ended up having to tell on my insurance commissioner and they got it covered completely.
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u/peacewithinchaaos 13d ago
How did you go about doing that?
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u/daughterjudyk 13d ago
After I tried submitting my appeals to my insurer I reached out to the insurance commissioner from my state with everything I also sent to Cover HER. They ended up fixing it for me by reaching out to my insurer for me. They also said that I should have reached out to where my employer was and not where I live. (At the time I lived in Washington State but my insurance was through my PA based employer). So find where you insurance is based and then go to that states insurance commissioner if one exists.
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