Does Medicaid Cover Tubal Reversal?

Tubal ligation is elective surgery performed to sterilize a woman. The fallopian tubes are sealed so she cannot become pregnant. Reversal of this surgery is possible for some women who wish to become pregnant later. Medicaid does not cover this surgery as it is elective and not medically necessary. Studies show 6 percent of tubal ligation recipients later regret the surgery, so most patients are satisfied with the procedure.

History

• Medicaid became available as part of the Social Security Act of 1965. It was created to help low-income citizens afford health care. Medical need is another requirement of Medicaid.

Significance

• Tubal reversal is major surgery. Tubal ligation itself is only recommended for women who are sure they will not want to become pregnant in the future. Many patients are offered in-vitro fertilization instead of undergoing the surgery for tubal reversal. Medicaid does not pay for these procedures as they are not medically necessary.

Function

• The original procedure of tubal ligation involves sealing the fallopian tubes either by cauterization or with a small clip. This prevents the egg from traveling to the uterus to be fertilized. Many women have this procedure after they deliver a baby. It involves small incisions on the abdomen and can be performed on an outpatient basis. Tubal ligation reversal is more serious and requires anesthesia. In some cases a woman remarries and she and her new spouse would like to have a child. It is not always possible for the fallopian tubes to be reconnected. The dangers of any major surgery, such as bleeding and infection, are also present.

Considerations

• Patients should consider the risks and cost of tubal reversal carefully. For every 100 patients who undergo this procedure, 50 to 80 are able to conceive in the future. Scarring may exist from the original ligation and pregnancy may not be possible. The national policy guidelines from the Department of Health and Human Services in regard to Medicaid state that "No benefits are provided under this plan for the following: ... expenses subsequent to the initial diagnosis for infertility and complications, including but not limited to ... reversal of sterilization procedures."

Misconceptions

• It is a common misconception that Medicaid will pay for tubal reversal if the women decides to have children at a later time. Since Medicaid considers a tubal reversal an elective surgery and will not cover the costs, it is important that a woman fully understand that the potential of reversing a tubal ligation will depend on her ability to cover the costs by other means.