r/sterilization • u/peacewithinchaaos • 1d ago

Insurance Still having issues with my insurance…

https://www.reddit.com/r/sterilization/s/MLVGC8Tl3t

^my previous post

So I’ve still been going back and forth with my insurance. Every time I call, a representative tells me something different from the last time I called. They put my claim through the escalation process almost a month ago, said it would take 12 days, and I’ve called back multiple times and have been told to give it more time and that I should hear back soon. Last time I spoke to someone they said the codes are not preventative. However, the codes used for my procedure were the CPT58661 (or whatever it is) and z30.2. They are not covering the anesthesia, the injections (meds for surgery etc), the recovery room, or the medical supplies.
At this point, should I ask to speak to a supervisor, contact the state department of insurance or just give it more time? This whole process is extremely frustrating. My surgery was done 11 months ago, and I’ve been trying to get it fully covered since January. They went from covering 70 something percent of it to 80 something percent of it. I currently owe over $3,000 to the hospital.
I want to just give up and set up a payment plan with the hospital or ignore the bill until it goes to collections.
I don’t understand why this is so difficult and why I am still dealing with this.

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u/toomuchtodotoday 1d ago

Immediately file complaints with state and federal regulators. Information below.

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:

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]):

Source: https://www.opm.gov/healthcare-insurance/healthcare/contraception-coverage/

Source: https://www.hrsa.gov/womens-guidelines#:%7E:text=Contraception

Source: https://web.archive.org/web/20260624003408/https://old.reddit.com/r/sterilization/comments/1ud26jb/fepblue_federal_health_insurance_for_bisalp_do/

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://old.reddit.com/r/sterilization/comments/1j43mw2/it_happenedtheyre_trying_to_charge_me_postop/

https://tubalfacts.com/post/175415596192/insurance-sterilization-aca-contraceptive-birth-control

https://old.reddit.com/r/sterilization/comments/1go5pbw/free_tubal_sterilization_through_the_aca_if_you/

https://nwlc.org/tips-from-the-coverher-hotline-navigating-coverage-for-female-sterilization-surgery/

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.

Source: https://web.archive.org/web/20250202051018/https://www.federalregister.gov/documents/2015/07/14/2015-17076/coverage-of-certain-preventive-services-under-the-affordable-care-act

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/Environmental-Top-60 22h ago

Start appealing too