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Infertility Benefit FAQ

Beginning January 1, 2022, Participants (and their covered spouses) enrolled with active coverage (this includes Extended Coverage), will be eligible for medically necessary infertility treatment coverage through Carrot, a comprehensive network of infertility treatment benefit providers. If during the course of treatment the Participant loses active coverage, the Participant and spouse may elect COBRA. 

Note: coverage under the COBRA benefit is only applicable to a Participant and/or their spousal dependent when they lose active/earned coverage during the course of infertility treatment through Carrot; this is referred to as continuity of care, allowing the Participant and/or their spousal dependent to elect the COBRA benefit to complete their course of treatment.

WHAT DOES THE FUND’S INFERTILITY TREATMENT BENEFIT COVER?

The Fund covers medically necessary infertility treatment for Participants and their covered spouses with a medical diagnosis of infertility, provided that the individual receives treatment from a Carrot provider.  Infertility treatment coverage is limited to a lifetime maximum of $30,000 per eligible individual.  Co-payments and deductibles do not apply for covered infertility treatment.

(Note: Please see the Summary of Material Modifications (SMM) and/or go to our website here for a list of covered services.)

WHAT IS THE CARROT CARD? HOW DOES IT WORK WITH THE FUND’S INFERTILITY TREATMENT BENEFIT?

Once you enroll in Carrot, you may request a debit card that is linked to Carrot providers – the Carrot Card.  If you are eligible for the Fund’s infertility treatment benefit, you may use the Carrot Card to pay for covered infertility treatment services from Carrot providers up to a lifetime maximum of $30,000. When you seek covered infertility treatment services at a Carrot-approved provider, you simply present the Carrot Card for payment; you don’t pay anything out of pocket. To get a Carrot Card, you will need to request one through the Carrot portal.

This is a new benefit, and there may be questions. The information provided in the SMM (sent to all Participants), can also be found on our website. You can sign up for Carrot HERE.

If you have any questions about your new benefit, you can reach out to Carrot ([email protected]) or to the Fund. You can contact the Fund Office during normal business hours at: (818) 846-1015 or toll-free (800) 227-7863 or email your questions to: ([email protected])

Please note that Carrot and the Fund Office answer questions as a courtesy to you. Any information they provide cannot be relied upon in a dispute concerning Plan benefits. If information that Carrot or the Fund Office provides is contrary to the Summary Plan Description or Summary of Material Modifications then in effect, the terms of the Summary Plan Description and Summary of Material Modifications shall govern.

HOW DO I GET STARTED WITH CARROT?

Participants and covered spouses attempting to conceive should create an account with Carrot by clicking HERE. You will receive a registration email from Carrot that includes a link to enroll in Carrot. If this doesn’t happen, or if you need help enrolling with Carrot, you can reach out to their Care Team at [email protected] and schedule a call with one of their Care Navigators.  

After creating your account, the next step is to get your free, personalized Carrot Plan by telling Carrot about yourself and your family-forming goals. 

HOW DO I PAY FOR INFERTILITY TREATMENT WITH CARROT?

Once you have registered, and created a Carrot Plan you will be allowed to request a Carrot Card within the Carrot portal. The Carrot Card will be sent to your home address. You will present this card at a Carrot provider when paying for covered services.

There is a $30,000 lifetime maximum per eligible Participant and per covered spouse and payments for covered services will be deducted from that limit. All questions related the Carrot Card can be directed to the Carrot Care Team directly through the platform or via email at [email protected]

If you forget your Carrot Card, you can pay for covered services by check, cash, or credit card and Carrot will reimburse you if the covered services are provided by a Carrot provider. You may want to use your own credit card when paying for covered services in order to get bonus points, cash back, travel miles, etc. If you’re going to pay with your own credit card, please make sure there is enough left of the $30,000 to cover the services.

Important: Regardless of whether you use the Carrot Card or you pay out of pocket for services, you should always confirm that the services are covered by the Fund’s infertility treatment benefit.  If you use your Carrot Card or pay for services that aren’t covered by the Fund’s infertility treatment benefit, you will be responsible for the full payment of those charges (and would need to repay the Fund for any amounts charged to your Carrot Card).

WHERE CAN I FIND A LIST OF WHAT IS AND IS NOT COVERED BY THE FUND’S INFERTILITY TREATMENT BENEFIT?

You should have received a Summary of Material Modifications (SMM) that explains what is and is not covered. You can find the document on our website here. You can also learn more about your benefits in your Benefits Guide, available through the Carrot portal by clicking HERE.

HOW DO I LOCATE A PROVIDER THAT ACCEPTS THE CARROT CARD? 

Carrot’s provider network is listed within the Carrot portal under Eligible Providers. If you need help finding Carrot providers, you can always schedule a call with a Care Navigator through the Carrot portal.

HOW DO I REVIEW HOW MUCH I HAVE REMAINING OF THE $30,000 BENEFIT?

You will be provided with an online portal as part of your initial sign-up process. You can see your remaining balance under Home or Transactions.

DO I HAVE TO SUBMIT CLAIMS FOR REIMBURSEMENT OR DOES THIS OCCUR AUTOMATICALLY?

You are always responsible for submitting claims for covered services provided by Carrot providers. This is the case regardless of whether you use your Carrot Card to pay for covered services or you pay for covered services out of pocket.

To submit a claim, you or your authorized representative will need to submit your claim directly to Carrot by uploading the paid statement or superbill from your Carrot provider through the Carrot portal HERE. Your claim must include: (1) the name of the individual who received the covered service, (2) the nature and date of the covered service, (3) the amount of the requested reimbursement, and (4) a statement that the covered service has not been reimbursed and is not eligible for reimbursement from another source (with the exception of reimbursement through your Carrot Card).

IS THERE A DEADLINE TO FILE CLAIMS FOR COVERED SERVICES?

Claims for covered services must be submitted to Carrot, which is the Claims Administrator, within 30 days after the first to occur: (1) the end of the calendar year of the date of service (regardless of when you are billed or pay for the service), or (2) the date your Fund coverage terminates (which is the later of the date you lose earned coverage or COBRA coverage, if you elect COBRA).  If you submit your claim after that deadline, your claim will be denied as untimely.  Claims for reimbursement must be submitted online through your Carrot account.

IF A PARTICIPANT HAS SERVICES ON DECEMBER 15, 2022, WHEN DO THEY HAVE TO SUBMIT THEIR CLAIM?

The Participant would need to submit their claim by January 30, 2023.  You have until 30 days after the end of the calendar year to submit claims for reimbursement for care received in that calendar year. 

DOES CARROT HAVE FERTILITY SUPPORT SERVICES?

Carrot provides virtual chats with doctors (including OB/GYNs), doulas, midwives, lactation consultants, and emotional well-being experts. They also provide resources on anxiety reduction, including prenatal yoga and meditation classes. You can learn more about your benefit in your benefits guide through the Carrot Portal.

DOES THE FUND’S INFERTILITY TREATMENT BENEFIT COVER PHARMACY COSTS?

Yes, infertility treatment medication costs may be applied against your $30,000 lifetime limit.  You will need to submit your claims for reimbursement for infertility treatment medications to Carrot, the same as for any other covered services.  You must use Express Scripts to fill infertility-related prescriptions, as explained below.

DO I GO THROUGH EXPRESS SCRIPTS TO FILL INFERTILITY-RELATED PRESCRIPTIONS, AND DO I HAVE TO PAY OUT-OF-POCKET?

Yes, you would utilize Express Scripts for all infertility-related pharmacy services and will pay the full cost of the prescription at the point of sale. You may submit your claim for reimbursement of the prescription cost to Carrot and/or you may use your Carrot card to purchase the prescription. All approved infertility-related pharmacy costs will be reimbursed by Carrot, subject to your $30,000 lifetime limit.

WHO DO WE CALL IF WE HAVE A CONCERN REGARDING ISSUES WITH INFERTILITY TREATMENT PAYMENTS? 

Carrot’s Care Navigation team is available M-F, 5:30 AM to 6 PM PST and will respond to most issues within 24 hours (during normal business hours, Monday through Friday). You can schedule a call with a Care Navigator through the Carrot portal.

AM I ELIGIBLE FOR COVERAGE UNDER THE FUND’S BENEFIT IF I AM ALREADY RECEIVING INFERTILITY TREATMENT?

As long as your treating provider is part of the Carrot network and you have qualifying Fund coverage, you should be eligible for the Fund’s infertility treatment benefit. You can create your Carrot account and schedule a chat with a Benefits Expert to arrange a seamless transition, especially if you’re already working with a specific infertility treatment doctor or clinic.

If the doctor or clinic you are working with is not part of the Carrot network, you will need to seek out a new provider or get tour existing provider to sign up with Carrot’s network.

You’ll also gain access to extra educational materials, and emotional support. If you have qualifying Fund coverage on the date of service on and after January 1, 2022, you can also submit your claim for reimbursement through your Carrot account. Just make sure to upload your provider’s itemized bill, and reach out to us at [email protected] with any questions.

CAN MY COVERED ADULT CHILD USE CARROT’S SERVICES?

Unfortunately, the Fund’s infertility treatment is only available to Participants and their covered spouses.  

WHAT IF I LOSE MY FUND COVERAGE MID-TREATMENT? 

As long as your treatment’s date of service is on or before your last day of Fund coverage your treatment will be covered.  Any treatment provided after your last day of Fund coverage will not be covered. Your Care Navigator will continue to be available to provide you with advice, even if your Fund coverage has ended.

MY SPOUSE AND I ARE BOTH COVERED PARTICIPANTS, DO WE HAVE $60,000 OF COVERAGE FROM CARROT?

You each have lifetime coverage of $30,000, which will be applied individually as appropriate.  You cannot “combine” your coverage with your spouse to apply the $60,000 limit toward one individual’s treatment. 

Example: You and your spouse both have Fund coverage and have made the decision to pursue in vitro fertilization (IVF).  You incur $45,000 of expenses related to IVF procedures (ovulation induction, egg retrieval, embryo transfer), and your spouse incurs $5,000 of expenses related to sperm analysis and retrieval.  You would be eligible for $30,000 of coverage.  The remaining $15,000 of your IVF expenses are not covered, because they exceed your $30,000 lifetime maximum.  Your spouse’s expenses of $5,000 would be covered in full, and he has $25,000 of remaining lifetime coverage.

HOW DOES IT WORK IF BOTH THE PARTICIPANT AND THEIR DEPENDENT SPOUSE HAVE INFERTILITY ISSUES?  ARE EACH OF THEM ELIGIBLE FOR THE $30K LIFETIME BENEFIT?

If the Participant and their dependent spouse each have Fund coverage, then each has $30,000 of lifetime coverage.  If the Participant is a covered member, but the Participant’s spouse does not have Fund coverage, then only the covered Participant would have $30,000 of lifetime coverage that could be applied to the Participant’s individual expenses, as appropriate.

CAN I USE CARROT’S SERVICES TO FREEZE MY EGGS OR MY SPOUSE’S?

Short-term fertility preservation may be covered if the Participant or covered spouse is scheduled to undergo a procedure that will result in a loss of fertility, such as radiation or chemotherapy.   The Carrot team can determine if the short-term freezing of eggs is considered a medical necessity in your situation.

DOES CARROT PROVIDE INFERTILITY TREATMENT TO SAME SEX COUPLES?

The Fund’s infertility treatment benefit covers medically necessary infertility treatment related to a medical diagnosis of infertility for all Participants and covered spouses, including same sex couples.

MY SPOUSE AND I WANT TO HAVE CHILDREN. WE ARE CONSIDERING USING A SURROGATE. IS SURROGACY COVERED UNDER THE FUND’S INFERTILITY TREATMENT BENEFIT?

No, surrogacy and its associated expenses are not covered.

CAN I USE CARROT FOR EXAMS AND/OR TESTS TO DETERMINE INFERTILITY?

The Fund currently provides coverage for an initial office visit and any testing to make a diagnosis of infertility, consistent with the Fund’s rules that apply to covered health benefits.  You do not need to use a Carrot provider for the initial office visit and tests to determine the cause of infertility.  For a list of providers who are part of the Fund’s PPO network, you should contact the Fund at [(818) 846-1015 or toll-free (800) 227-7863)].  Once a medical diagnosis of infertility is made, the Fund will cover subsequent medically necessary infertility treatment up to $30,000 lifetime maximum, as long as you use a Carrot provider for the treatment.

WHAT IF I DECIDE TO OBTAIN INFERTILITY TREATMENT FROM A PROVIDER WHO IS NOT PART OF THE CARROT NETWORK? CAN I SUBMIT MY BILLS TO THE HEALTH FUND?

If you receive infertility treatment from a provider who is not part of the Carrot network, the infertility treatment will not be covered by the Fund and you will be responsible for payment in full.

WHAT IF I WANT TO APPEAL A DENIED CLAIM BY CARROT?

If your claim is denied in whole or in part by the Claims Administrator, you or your authorized representative may file an appeal to the Appeals Administrator.

You should email your written appeal to: [email protected] with the subject “Appeal Requested for Denied Claim.” You have 180 days from your receipt of the claim denial to file a written appeal. If you do not file your appeal within 180 days after receiving the Claims Administrator’s decision denying your claim, the Claims Administrator’s decision is final and you will not be allowed to pursue a claim in court.

CAN I APPEAL TO THE HEALTH FUND IF I AM NOT HAPPY WITH THE RESULTS OF MY CARROT APPEAL?

If you do not agree with the Appeals’ Administrator’s decision on appeal, you may file a voluntary appeal with the Health Fund’s Benefits Committee, but are not required to do so.  During the period between when you submit your voluntary appeal (if any) and the Benefits Committee’s decision, the legal deadlines that would otherwise apply to your right to file a legal action in court in connection with the claim denial will be tolled.