How I Got the RAMQ to Pay for Fertility Preservation Undertaken Prior to HRT

Special thanks to Taowa and Arwyn for their feedback.

The Short Version

I sought sperm freezing at a private clinic in Montréal that charged me for its services. I submitted an online request to the RAMQ for a reimbursement of the first two years of expenses, stating that I was wrongfully charged by the clinic (this service is covered by the RAMQ even at private clinics). My request included:

• Paid invoices for the first two payments I made to my fertility clinic for sperm freezing (billed annually).
• A letter from my family doctor (who is also my hormone provider) on clinic letterhead, stating that I sought fertility preservation because of HRT, and that HRT is both gonadotoxic and medically necessary.
• A letter of my own writing, which explained that the clinic had told me the service was not covered by the RAMQ, and that I believed I had been wrongfully charged.
• A PDF of an email I received from my fertility clinic, stating that the service was not covered.

I do not know if any of the last three were required. More details on each of these items can be found in the section “Request for Reimbursement”.

The RAMQ sent me a letter stating they needed additional time to process my request. I asked, by registered mail, for more information on how they were evaluating my application, and for a phone number and extension of someone with knowledge of my application. The request was approved a few weeks later, and I soon received a cheque for the full amount of both payments. The total time from when I filed my request to when I received the cheque was a little over five months.

Context

On November 15th, 2021, certain sections of Law 73 came into force in Québec, extending coverage by the RAMQ of assisted reproduction services including fertility preservation. These services are covered under the RAMQ Medically Assisted Reproduction Program. As stated on the program’s website:

Freezing of gametes for fertility preservation is covered to age 25 or 5 years for people age 21 and over. The service is available to people before undergoing gonadotoxic treatment or ablation of the ovaries or testicles. Gonadotoxic treatments are treatments toxic to the ovaries or testicles. They may be cancer treatments or involve medications that can cause permanent infertility.

Treatments covered as fertility preservation services include

• up to two ovarian stimulations as per medical indications,
• one egg retrieval,
• standard IVF services,
• one surgical sperm cell collection, and
• freezing and storage of a sperm sample, oocytes, or embryo

Relevant section of the Regulation respecting the application of the Health Insurance Act (as of 2023-08-20).

In the fall of 2021, I was seeking fertility preservation so I could begin feminizing hormone therapy without worrying about my fertility. Whether or not this would be covered by the RAMQ basically boiled down to whether or not they considered HRT to be gonadotoxic. Prior to Law 73, fertility preservation was covered only for cancer patients. In the exchanges I had with the RAMQ and with my fertility clinic, both said the service was only covered in that case, even when I brought up Law 73. Even now, fertility clinics don’t always mention that their services are covered for any gonadotoxic procedure (example).

I also found that not all doctors are willing to describe HRT as gonadotoxic. When I asked my first hormone provider (who is known among their patients for their over-insistence on fertility preservation) for a letter to support my request to the RAMQ, they refused to use the term when asked explicitly, stating only that HRT “can affect [my] fertility”. The same doctor also refused to state that HRT was medically necessary “because of insurance”, despite the fact that it was deemed medically necessary by the WPATH standards of the day (version 7). Later, my second hormone provider wrote a letter stating that HRT was both gonadotoxic and medically necessary, in stark contrast to my first.

This puts patients seeking HRT in an awkward position. Our doctors typically advise us to consider fertility perservation prior to HRT, but because it does not permanently destroy a person’s fertility in all cases, and because there is (in my opinion, unreasonable) disagreement over the medical necessity of HRT, insurance coverage is uncertain. It is also appears quite possible that fertility perservation sought prior to HRT was not in the minds of those who wrote Law 73.

Nevertheless, the RAMQ agreed to reimburse me for my fertility preservation when I submitted a request for reimbursement in early 2023. This page details my request, and the correspondence that ensued before is was approved.

Please note that the information on this page is not legal advice. That said, it may be useful to someone providing you with legal advice.

Services

I sought sperm freezing at a private clinic in Montréal. The service is billed annually. I made my first payment in January of 2022, after I was told verbally that the service would not be covered by the RAMQ (note that this was after the relevant section of Law 73 came into force). Prior to my second payment, I asked the clinic again by email if the service would be paid for by the RAMQ. This was their reply:

Good day [Name],

Thank you for having communicated with us.
I have reviewed your attached file and unfortunately, the storage of sperm is not covered by RAMQ.
Under the exception of Oncology reason will the RAMQ cover the storage for patients for 5 years.

Therefore, you will be invoiced annually for the storage of your samples.

Please feel free to contact me if you have any questions.

Kind regards,

After that, I made my second payment on January 12, 2023.

Request for Reimbursement

I filed my request for reimbursement for the two payments online on January 17, 2023. My request contained the following:

• Paid invoices for the first two payments I made to my fertility clinic for sperm freezing (billed annually).
• A letter from my family doctor (who is also my hormone provider) on clinic letterhead, which said the following:

À qui de droit,

[Legal name] ([Preferred first name]) à fait l’entreposage de sperme débutant en 2022. Ceci est à cause de l’utilisation d’hormones qui sont gonadotoxique. Ces hormones sont une nécessité médicale pour le traitement de dysphorie de genre.

Bien à vous,

[Signature]

[Doctor’s name]

English translation:

To whom it may concern,

[Legal name] ([Preferred first name]) began sperm preservation in 2022. This was done due to the use of hormones, which are gonadotoxic. These hormones are medically necessary to treat gender dysphoria.

Kind regards,

[Signature]

[Doctor’s name]

My doctor made a point of writing the letter in French, because the RAMQ does not generally provide good, fast service in English. They also made a point of mentioning gender dysphoria, despite the fact that they do not typically use the diagnosis in their practice. The clinic’s letterhead contained the clinic’s contact information.

• A letter of my own writing, which said the following (in French):

À qui de droit,

Notez qu’avant les deux paiements vers [clinic], la clinique m’a confirmé qu’elle n’était pas capable de rembourser les frais de services présentés. Cela était communiqué vocalement avant le premier paiement et par courriel avant le deuxième paiement. La requête n’est pas reliée à ma capacité de présenter ma carte d’assurance maladie.

Merci,

[Name] (she/elle)
(Nom légal “[Legal name]”)

English translation:

To whom it may concern,

Note that before each of the two payments to [clinic], the clinic stated that it was not able to reimburse the cost of these services. This was communicated vocally prior the first payment and by email prior to the second payment. This request is not linked to my capacity to present my Health Insurance Card.

Thank you,

[Name] (she/elle)
(Legal name “[Legal name]”)

• A PDF of the email I received from my fertility clinic, stating that the service was not covered (see above).
  
  

I have not published this list as a proposed list of requirements for others to follow. I do not know if any of the last three items were required. I submitted them using the “Send documents related to a request already in progress” menu option on the online portal, after submitting my initial request.

Note that the RAMQ distinguishes two main kinds of requests:

• Patients who had an expired Health Insurance Card, or were unable to present their Health Insurance Card, at the time of their appointment—Patients in this situation have up to one year to file a request for reimbursement, and they are required to provide information on the health professional who provided the services (practice number optional).
• Patients who were wrongly charged—Patients in this situation have up to five years to file a request for reimbursement, and they are not required to provide information on the health professional who provided the services.

This is why I included a letter explaining that I was not filing a request for reimbursement because I failed to present my Health Insurance Card, and that the clinic stated the service wasn’t covered. It had been more than one year since my first payment by the time I filed my request. Again, it is possible my request would have been accepted even if I left out that letter, I don’t know.

The RAMQ tries to process requests in 60 working days and notifies claimants in writing when they must exceed that time frame. If you file a request, I recommend that you mark this deadline on your calendar, in case the RAMQ does not get back to you.

Correspondence

Two and a half months after submitting my request, I received this in the mail:

The letter opens with “Sir” and uses my deadname (redacted), despite the fact that my correct name and pronouns were specified in a letter I submitted with my request.

I sent the following reply by registered mail on May 17th, 2023:

To whom it may concern,

I am writing in response to a letter I received about a request for reimbursement (copy enclosed). My health insurance number is [Health insurance number].

Thank you for providing additional information on the status of my request. So that I may better prepare in the event of a refusal, please inform me in writing of the nature of the additional checks required to process my request, including criteria that will be used to determine whether the request is refused.

To ensure this process goes smoothly, please also provide a phone number with extension for someone with knowledge of my request who will be able to answer questions about its status.

Lastly, please use feminine language (e.g. “Madam”) and, when possible, my preferred name [Name] in future correspondence. The Directeur de l’état civil is currently processing my application for a name change to [Name] and a change of sex designation to Female.

Best,

[Name] (she/elle)
(Legal name [Legal name])

A few weeks later, I received the following response:

Using my correct name, the RAMQ agreed to reimburse the full amount for both payments, including the payment made over one year prior to my request. I received a cheque soon after. In total, the time from when I filed my request to when I received the cheque was a little over five months.

Final Remarks

I hope this helps anyone else looking to request a reimbursement along similar lines. I will be reaching out to the RAMQ to ask for more details on the requirements for this coverage, and to encourage them to publish those requirements on their website and make it easier for patients seeking HRT to access this program without paying up-front. I will post updates here.

Always remember that the government has long provided free fertility preservation to cancer patients. Asking them to cover it for us when we seek hormones, and especially when we seek surgery, is asking for equal treatment. We have just as much of a right to be parents, moms, and dads as anyone else.

🏳️‍⚧️