- It’s important to understand how to advocate for benefits not already included in your policy, such as coverage for infertility-related medical care and gender-affirming medical services.
The majority of Americans receive their health insurance through their employer. The validity of this model—as compared to, for example, universal health insurance provided by the government—has recently been a hot topic of debate in US politics. For the foreseeable future, however, most Americans will continue to access their health insurance through their employer. Therefore, it’s important to understand how to advocate for benefits not already included in your policy, such as coverage for infertility-related medical care and gender-affirming medical services (GAS).
Employer-based health insurance is a benefit the employer provides where the employee agrees to pay a certain premium and deductible. In return, the insurance provider pays for the medically necessary services identified in the policy agreement (PA). Importantly, health insurance coverage doesn’t mean a recipient should expect to have all services covered simply because a health care provider determines they’re necessary for their health. Rather, covered services are limited to those identified in the PA.
All employees who receive employer-based health insurance are entitled to the most up-to-date copy of their PA. Typically, these are provided by the employer annually during re-enrollment (usually in the fall or winter). However, if you don’t have a recent version of your policy, you can request one from your human resources representative or the person otherwise responsible for managing the employer-based policy.
Once you’ve obtained a copy of the PA, read the benefits. PAs are often long, but only a small section will pertain to the specific services you’re interested in. It may be tedious to find the specific section but persevere.
After reading the appropriate section of your benefits, consider whether the coverage you seek is simply omitted or explicitly excluded. For example, it was standard practice for a long time to include an explicit exclusion for “transsexual services.” Although the term transsexual is considered outdated by many because these exclusions have not necessarily been reviewed, they remain included in many policies today. It’s also important to note that an insurance provider has default provisions for many services (including infertility and GAS) that may be reflected in your policy. These do not necessarily reflect choices made by your employer.
A handful of states have mandates around the inclusion of infertility services in health insurance coverage. However, there are generally two types of mandates: IVF mandates and other infertility mandates. Each policy may differ. States that mandate IVF coverage require that all policies provide coverage for infertility services, including IVF, as an insurance benefit; however, the specifics are state-dependent.
There are no federal laws specifically concerning the inclusion of infertility-related medical services or GAS in health insurance policies. However, state and federal laws regarding nondiscrimination practices in health insurance policies exist.
Human Resources is often responsible for managing or participating in health insurance policy plan decisions. Therefore, HR is usually a good place to start. First, consider what approach will be best received. While it may be frustrating to find out your health insurance plan doesn’t provide the coverage you need, remember that you’re reaching out to your employer with the ultimate goal of getting that changed rather than placing blame.
Begin by identifying the gap in coverage or exclusion and trying to identify why your policy doesn’t currently provide the coverage you need. Consider starting communication with an email or otherwise in writing. This will help you make your correspondence as clear as possible, and hopefully, you’ll get a response in writing that you can build from. Occasionally, raising the issue will be sufficient to see the change you seek. However, in most cases, you’ll be engaged in several more conversations before any progress is made. An in-person meeting with the decision-makers and other potential ally coworkers may be an important step to advocate for your position. It’s important to bring your legal research with you to this meeting. At the very least, regular communication with the identified decision-maker will ensure the issue remains a priority for your employer.
Before an in-person meeting, you may also want to consider why the coverage you seek is not currently provided. This will give you insight into how best to make your case for inclusive coverage. Consider some of the following reasons.
This is often the easiest fix. Many policies omit coverage for healthcare related to IVF or GAS. In part, this is because these policies were not historically required by law and, therefore, not standard in the industry. There’s also a history of discrimination against these types of coverage. While our culture and the industry have come a long way, that discrimination lingers in the default policies we see in place today.
If cost is cited as the reason for excluding these policies, you may need to do additional research. However, start by asking for the numbers. If cost is really the reason, then it’s reasonable to assume your employer has done the analysis and should have the numbers to compare. Alternatively, whichever company your place of employment works with to provide coverage should easily be able to provide quotes to include a new type of coverage. This will allow you to evaluate the validity of the cost argument.
But don’t stop there. Even if the inclusion of the service you want appears to be more expensive, the actual cost of the policy is not the only financial consideration. Companies should consider whether they are competitive in their area. Do they risk losing good employees to a competitor willing to provide this type of coverage? They need to consider what hidden expenses there might be for the company when they don’t provide these services, such as employees taking on a second job to afford their healthcare, which increases their stress and fatigue and reduces productivity in the workplace.
If coverage was excluded because it’s against the company’s policies, identify the specific policy, motto, mission statement, etc., that’s allegedly contrary to the inclusion of the coverage you seek. It’s sometimes tempting for employers to hide their own discriminatory beliefs behind the official position of the larger company. However, do not confuse these two. Personal animus or bias are not valid reasons to exclude medically necessary health coverage in an employee-based policy.
Once the policy has been identified, consider whether the inclusion of the coverage you seek is truly at odds with the policy. If it is, you may want to consider whether it’s possible to change this policy. Alternatively, you may consider whether you want to continue working at a company that has implemented such a policy.
If the policy is not in conflict, raise this issue with the person you’ve been in discussions with. But be prepared to elevate this to their supervisor.
You can advocate for yourself, your family, and your colleagues by being familiar with your employer-based health insurance, your policy’s benefits, and its exclusions. The road to successfully changing a health insurance policy is often long: expect to work on this for at least a year. Further, it can be a lot of work. However, you’re entirely capable of being this type of advocate. The resources you need are available to you either through your employer, legal research, or online research. Further, if you’re successful, you will provide a great benefit not only to yourself but also to those who work with you.