Does Medicaid Cover Tubal Ligation Reversals?

The general rule of thumb is to avoid tubal ligation unless you are 100 percent sure you no longer want children. But what happens if you had it without getting good advice and have now changed your mind?

What should you do to change your circumstances? And what if you don’t have the budget for it and are on Medicaid?

It would be best if you first understood what tubal ligation reversal involves, its associated costs and whether you can get Medicaid to cover tubal reversal and offer you a way out of your dilemma.

When getting your tubes tied, your doctor will tie, block or cut your fallopian tubes as a form of birth control. When that happens, your eggs will not get fertilized when you have sex. And so, your chances of getting pregnant will be almost nil.

Usually, this procedure happens under general anesthesia. However, you can have it done under local anesthesia and go home the same day.

However, don’t kid yourself that the operation is minor because it’s not. For many people, it is a permanent form of birth control and causes sterilization. In addition, it can cause other problems.

If you change your mind and decide you want another baby, you could go back to a medical facility and get a tubal ligation reversal done. During this process, the doctor will reattach your Fallopian tubes after removing any existing obstruction. However, you should remember that ​20 to 50 percent​ of women may fail to conceive after the reattachment.

You could always opt to pay for tubal ligation out of pocket. But it would cost you anywhere from ​$5,000 to $8,000​. It depends on where you live and the doctor who performs the procedure.

Unfortunately, many health plans do not offer coverage for this kind of thing. But for those who do, you would need to pay your fair share in co-pays and co-insurance expenses of ​10 to 30 percent​. And these could add up to ​$2,000​ or more in out-of-pocket expenses.

Medicaid tends to provide health insurance coverage for people with low incomes who meet the set criteria. These people usually include children, pregnant women, people with disabilities and the elderly.

Getting Medicaid to cover some procedures can be challenging. You have to meet the strict federal requirements before you can get your tubes tied. So, you would need to be at least ​21 years​ old, mentally competent, have provided informed consent under §§441.257 and 441.258 and have waited for at least ​30 days​ since you provided that consent.

However, in exceptional cases, such as when you undergo premature delivery, you can get your tubes tied so long as three days have elapsed since you gave your informed consent.

Federal guidelines on how funding can be used for sterilization exist to safeguard people from possible coercion, as has happened in the past against members of minority groups.

If you voluntarily obtained tubal ligation, it follows that insurance companies are unlikely to pay for the reversal procedures because they consider it elective. So, it’s safe to assume that if Medicaid sets such strict requirements for tubal ligations, it will do the same for tubal reversals.

And generally, you will not receive coverage for the procedure because it is too expensive. But it is possible to get the reversal under some circumstances.

If you can prove a medical need for tubal reversal, you could get Medicaid to cover tubal reversal to a limited extent. And that requires that you show the reversal will treat, prevent or help diagnose other diseases or symptoms.

For example, if you end up with Post Tubal Ligation Syndrome (PTLS) arising from damaged blood supplies to your ovaries and your estrogen or progesterone hormone levels quickly drop and cause other issues, Medicaid may finance the tubal reversal procedure.

However, changing your mind about having another baby is not a good enough reason. If you belong to this category, you would be better off taking advantage of any IVF coverage you have if you live in a mandated state and no exclusions apply.

Also, you can apply for fertility grants, such as the Pay It Forward Fertility Foundation grant or the Tinina Q. Cade Foundation’s Family Building Grant. While there is no guarantee that you will get the funding to reverse your infertility, it’s worth trying out. In addition, you could also consider adoption or fostering as viable ways of parenting.

You may not want to rely on Medicaid to cover tubal reversal. The odds are pretty high that you will not get help unless you provide a provable medical reason. So, you are likely to be disappointed.