Will Health Insurance Cover Your Vasectomy
Will Health Insurance Cover Your Vasectomy?
Most likely your health insurance will cover your vasectomy procedure. Over 85% of plans will cover vasectomy. If a health insurance plan does not cover vasectomy it is usually a religious based health plan or a very low cost health plan.
Coverage for vasectomy is not usually the problem. The main question that needs to be answered is do you have a deductible and how much have you paid towards your deductible?
Coverage. Coverage is a term that means do they see the medical treatment as important and necessary. Over 85% of health insurance plans will offer vasectomy coverage.
Coverage is usually not provided for elective procedures considered not medically necessary. For example, they may offer coverage for vasectomy but do not offer coverage for infertility or cosmetic treatments.
Most plans will cover vasectomy but you will need to clarify your coverage with your health insurance company.
Deductible. An amount you must pay towards your health care treatment before health insurance begins to make payments on your behalf. Deductible amounts reset every year.
The most important question that needs to be answered is do you have a health insurance deductible? If so then how much is the deductible and how much have you paid towards your deductible?
Deductible amounts are a moving target.
If you do not have a deductible, then they may pay for the full amount.
If you have a high deductible plan, for example $5,000, then you are responsible for the first $5,000 of your health care. After you have paid the first $5,000 then they will start paying for any additional treatments if they are covered.
Deductibles reset every year. The deductible is what makes it more complicated.
- If it is the start of the year and you have not paid towards your deductible then you will pay up to the amount of your deductible. After that the health insurance company will cover the rest of your health care expenditures.
- If it is the end of the year and you have paid your deductible amount then your health insurance will cover the rest of your health care expenditures.
- If you have not paid anything towards your deductible then you will have to pay up to the amount of your deductible before health insurance kicks in.
All of the above sounds complicated but it really is not as complicated as it may seem.
Will Insurance Cover Your Vasectomy Procedure? Find Out In 2 Simple Steps!
Five steps required to verify vasectomy coverage.
Step 1. Call your health insurance customer care agent using the number on your health insurance card.
Step 2. Inform the agent you are trying to determine if you have coverage for vasectomy.
Step 3. Provide the agent with the codes of the procedure you are trying to obtain:
- Vasectomy with local anesthesia: Vasectomy office visit code 99205, Diagnosis code Z30.2, and Vasectomy procedure code 55250
Step 4. Inform them the doctor is designated as a specialist and the procedure is performed in the doctor’s office. The place of treatment code = 11.
Some health insurances will not pay you or will pay you much less if you go to an ‘out of network’ doctor.
You will have to ask them if His Choice is considered ‘in-network’ or ‘out-of network’.
Unfortunately, if a doctor does not accept health insurance, most health insurance plans will consider these doctors as being out of network.
Step 5. Have them clarify the following:
Is vasectomy covered? How much will you be reimbursed for your vasectomy?
You should inform them the doctor does not accept health insurance and you will be submitting a Member Claim Form after the procedure has been completed.
Using the information above your health insurance agent should be able to tell you if you have vasectomy coverage and how much you can expect to be reimbursed after you submit your Member Claim Form.
How to obtain reimbursement for your His Choice vasectomy procedure?
After your vasectomy procedure has been completed, you will need to request payment from your health insurance company.
- You will need the following:
A payment receipt from our office.
- An office superbill with the procedure codes. We will provide you with this information.
- A Member Claim Form. You can get this from your health insurance company.
Step 1. Pay for vasectomy on the day of service. We will provide you a receipt and superbill.
Step 2. Obtain a “Member Claim Form” from the website of your health insurance company.
Step 3. Complete the Member Claim form.
Step 4. Submit your Member Claim form to your health insurance company for reimbursement. You will need to include your payment receipt and office superbill that we provide you.
Submit the completed Member Claim form with a copy of the receipt and office superbill.
Below are sample completed Member Claim forms with the correct billing codes demonstrating how the form should be completed to obtain vasectomy procedure reimbursement from your health insurance company.
The form will be completed differently depending on if you have 1 or 2 office visits.
Vasectomy performed during a single office visit.
Most patients will use this form. If you have your vasectomy done under local anesthesia during a single office visit then complete your Member Claim form like this sample form demonstrates:
Consultation visit only
If you choose to have a consultation visit before your procedure then complete your Member Claim form like this sample form demonstrates:
Vasectomy procedure after a consultation visit
If you had a consultation first and then returned on a separate date for a procedure under local anesthesia then complete your form as this sample form demonstrates:
Technically, you should be able to submit the codes for the two visits on one Member Claim form…you would need to indicate the consult and the procedure were done on separate dates when you complete the form.
You would also need to include the two separate receipts provided by our office. The receipts need to have dates and codes that exactly match your completed Member Claim form.
If you have any questions then contact your health insurance company and they will be able to assist you.