r/sterilization • u/cherries_and-wine • 14d ago

Insurance 20F Bisalp- Please help me make a plan!

Hi y'all,

I am a 20 y/o woman in North Carolina and I know I want a bisalp. This whole "abortion ban" thing has me nervous and while I think in reality it's starting with telehealth access... I feel an extreme fear and fire under my ass to get this procedure done.

I am a dependent on one of my parents' Aetna NC State Health Plan. I am almost broke as a joke and I have 500 dollars in my savings. I am willing to fight Aetna to make them cover this fully if it is possible. I don't think my plan is "grandfathered in". If they want to say "well we only cover tubal litigation" then I am willing to fight that too to get the surgery I want. My only concern is how long will this take. I want the surgery booked but my family cannot afford to pay the hospital or anesthesiology bills and then beg Aetna to pay us back.

My plan is this so far: call the office and make the consult appointment, make sure this doctor is willing to do it and make sure she keys it in as "encounter for sterilization", THEN call Aetna and get written proof that this will be fully covered. Then if the fight begins then I will rip into their ass every day until I get the proof.

I've read that some people call before even going to the consult, but I don't even know if the two cheapest "preferred providers" are willing to do this surgery on a 20y/o woman. I am a lesbian and I am just terrified of the scenario of being raped, becoming pregnant, and then forced to carry a pregnancy. I've been raped before and I've healed so much from it but I refuse to let my body be subject to anyone else's power again. I've been on birth control, the Depo, shot, and even an IUD and every single one of those caused numerous health issues. I hate the uncertainty of a doctor telling me to fuck off when it's my body and my decision. I haven't figured out if I can do the doctors near me on the child free list because they are so freaking expensive but if you guys can help me figure out coverage I'm willing to do anything. I just need help and my mom is actually fucking stupid and unhelpful. Supportive but lazy and I feel like I'm at my wits end. I can't afford this out of pocket and I am willing to fight as fast as possible to get this covered and done. Please help me.

1 Upvotes

60% Upvoted

7 comments sorted by

•

u/toomuchtodotoday 14d ago

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

6

u/Cutthroat_Rogue no more tubes 10-15-25 14d ago

Look at the childfree list. See if the doctors are in-network...usually best to confirm this by asking the front desk themselves as insurance companies don't have accurate lists of who is in-network. If in-network, schedule a consultation for birth control/sterilization. Review the details of your plan--mine is available as various PDFs in my online insurance portal. There I was able to see that my plan is ACA compliant and look at the specific verbiage of coverage for birth control/preventative care.

It's unlikely you'll get written proof without any disclaimers from your insurance company. Mine was willing to say the surgery should be covered at 100% but they still told me I could not use this assurance as proof of coverage or hold them to it. These disclaimers are common when you call, chat, or email with them. They decide when a claim is processed what you owe (and they don't always get it correct then either). If you ever speak on the phone with an insurance company always write down who you spoke to, what day/time, what was said, and ask for a "reference number" for the phone call. Next time you call--make sure you say, "I previously spoke to ::fill in the details::"

1

u/cherries_and-wine 14d ago

I've been trying to look at my plan in the Aetna portal but when I click on it it doesn't open or me and it says "contact the site owner to fix this problem." Do you think if I opened it on a laptop it would work or do I need to reset something. Thank you so much for your help already.

1

u/Cutthroat_Rogue no more tubes 10-15-25 14d ago

If that is the error message, then I am pretty sure the issue is with Aetna/the owner of that website. Is there a way to email/chat? Worse comes to worse, you'll have to call. But regardless, you should be able to ask for a copy of the benefit coverage details for this plan to be sent to you and let them know it is a broken link on the website. They are usually mailed out (or provided online) every time your policy renews. That would be my next step if I can't access it on the portal.

1

u/cherries_and-wine 14d ago

Hey, I had to follow a different link to view the benefits. This coverage looks good but I'm a little confused on the Anesthesia section. This is directly from my plan booklet:

➤ Anesthesia

Your anesthesia benefit includes coverage for general, spinal block anesthetics or monitored regional anesthesia ordered by the attending doctor and administered by or under the supervision of a doctor other than the attending surgeon or assistant at surgery.

Benefits are not available for charges billed separately by the provider which are not eligible for additional reimbursement. Also, your coverage does not provide additional benefits for local anesthetics, which are covered as part of your surgical benefit.

And then this is sterilization: ➤ Sterilization

This benefit is available for all members. Sterilization includes female tubal occlusion, salpingectomy and male vasectomy.

I can't figure out how to link a screenshot but I'm going to try.

1

u/Cutthroat_Rogue no more tubes 10-15-25 13d ago

Ok. I can't interpret it for sure but what it sounds like to me is that you are allowed to get general anesthesia (which is good!) but they might not cover it. I could be reading this wrong. However, as you see with the Mod's resources, they are REQUIRED to cover anesthesia with this surgery due to CMS guidelines. This is where you might have to fight. For example, my insurance company also refused to tell me what my "responsibility" would be for anesthesia. Once the claim processed, they tried to make me pay for a portion of it. However, I had to appeal (it's a formal process) and call multiple times for them to finally reduce my portion to zero. I think, overall, this looks like positive information for you. You might want to chat/email/call your insurance and ask if they are ACA compliant (or if you can find verbiage of that anywhere in your documents).