Disclaimer: We are neither attorneys nor accountants and this information is provided for educational purposes only. Please consult a competent financial planner, accountant and/or attorney for professional advice.
The single biggest obstacle to curing infertility is, in many cases, financial.
Most people ting that it’s because the procedure is so expensive, but the issue is not so much the actual cost, but rather the lack of insurance coverage available. While most insurance companies do offer optional coverage for certain infertility treatments, it’s often not included in employer plans.
As such, many are not able to seek treatment for infertility and those that are, often are forced to make decisions largely based on the financial aspect rather than on the best choice medically.
As we all know too well, infertility is a true struggle and more common than not, and we all have someone affected in our lives.
So, if you’re finding yourself facing infertility and seeking options for paying for your treatment, or trying to help a friend or loved one navigate the financial aspect of infertility treatments, here are some tips and ideas.
First things first… call your insurance provider and ask them what IS covered in relation to fertility treatment. For instance, many plans will not cover the actual treatment, but WILL cover the diagnosis. In other words, the initial testing could be covered so you can at least get the process started.
For example, if you have fibroids, or endometriosis, insurance may cover those treatments, but not IVF or IUI.
It is possible that infertility benefits are included, so it certainly makes sense to at least ask. The worst they can say is no.
It is also important to be aware that coverage can be found on both the patient’s insurance as well as the spouse or partner’s, so you should always research and explore the possibility to advocate for both.
Many patients are unaware that their spouses have coverage, or have had coverage all along.
TIP: Call 2-3 times and ask the same questions. You don’t always get the same answers when calling your insurance company, unfortunately.
Also, don’t rely on the health care provider to get the answer. Their information is only as good as the rep they spoke with and, again, you don’t always get the same information from different people. Many times coverage is found on a re-verification of benefits rather than the initial inquiry.
You can also talk to your HR person to see if you have the benefits. He/she may be able to give you more information on the actual benefits that you have access to.
Ultimately, it’s a good idea to get some of the diagnostic testing done beforehand so that you have an actual diagnosis and plan moving forward. The last thing you want is to jump through all sorts of hoops to get coverage only to find out that it doesn’t cover your particular needs. (for example, let’s say you need to use donor eggs, but the policy requires that you use your own eggs).
NOTE: While medications are often not covered in plans that DO include treatment as a benefit, they will sometimes apply towards your deductible, so be sure to ask.
Which Insurance Companies Cover Infertility
The truth is that they all offer about the same coverage.
In the state of Texas, for example, there is only one way to obtain insurance coverage for infertility treatment and that is through a group health insurance plan. You can’t purchase coverage as an individual.
In this case, the only option is to find an employer who offers coverage, convince your current employer to add the coverage or to purchase a group health insurance plan if you’re self employed.
In other words, if you have your own business, you may be able to get “group coverage” for as little as two employees (yourself and your spouse). While it may be costly, it could cover the majority of all of your fertility treatments after you meet your deductible, and wind up much less expensive than paying out of pocket for infertility treatments.
Types of Insurance Plans
There are two types of insurance plans
1. Fully insured policies; and
2. Self-funded policies.
Fully Insured Policies
Fully insured policies are policies that designed and offered by the insurance company and purchased by the employer. Plans that are “fully insured” are overseen by TDI.
If you want to advocate for coverage for a plan that is “fully insured,” then the request will need to be directed to the insurance company itself. They will be the ones to determine if an exception will be made.
In these situations, it is best to obtain the proper steps in applying for this coverage exception directly from the insurance carrier. It is also a very good idea for patients to include a letter from their physicians explain the medical necessity of the requested service.
Self-funded policies are policies designed and offered by the employer but then administered by the insurance company. Self-funded plans are overseen by ERISA. (ERISA should only be contacted if the patient wants to file a, “insurance” complaint against the employer).
If you’re covered under a “self-funded” plan, understand that the ultimate decision will be made by your employer.
You should inquire with the insurance company to confirm what steps should be taken to make this request properly, but it never hurts to reach out to the HR or benefit department directly.
Some people prefer to keep this information private and do not wish to go this route, but for some this is most effective.
Finding A Good Insurance Agent
It is important to find an agent with experience with infertility coverage. Unfortunately, the majority of agents don’t have this experience and may provide misleading – or bad – information to patients. While not intentional, it can be extremely costly to get bad information.
Always ask to read the rider in detail before spending the money on a policy to make sure your needs are going to be met with the particular policy. The last thing you want is to wind up with an expensive policy with coverage you can’t use.
This is why it’s also important to get a diagnosis BEFORE purchasing policies or getting exceptions to your policy.
In addition, coverage is available for both the medical services associated with infertility AND the necessary medications separately. A knowledgeable agent should be able to identify all coverages possible.
Insurance, in general, is very foreign to most people.
Here is a short glossary of common terms for understanding health insurance.
Allowed Amount – The highest amount an insurance company will cover (pay) for a service.
Coinsurance – How much you have to pay after you have paid your deductible. This is for covered services and may still require a copay. For example, your plan might cover 80% of your medical bill. You will be required to pay the other 20%. This 20% is the coinsurance
Coinsurance Limit (or Maximum Out of Pocket) – The most you will pay in coinsurance costs during a benefit period.
Copayment (Copay) – The amount you pay to a healthcare provider at the time you receive services. You may or may not have to pay a copay for each covered visit to your doctor, depending on your plan. Not all plans have a copay.
Covered Charges – Charges for covered services that your health plan paid for. There may be a limit on covered charges if you receive services from providers outside your plan’s network of providers.
Covered Person – Any person covered under the plan.
Deductible – The amount you pay for your healthcare services before your health insurer pays. Deductibles are based on your benefit period (typically a year at a time). Learn about deductibles here. This period may start on January 1 or may have a different fiscal year. For example, if you have a $2000 deductible, you will be responsible for the first $2000 before your insurance pays anything. After that, the insurer will cover the rest*
* See Coinsurance above
FSA (Flexible Spending Account) – An FSA is often set up through an employer plan. It lets you set aside pre-tax money for common medical costs and dependent care. FSA funds must be used by the end of the term-year.
HSA (Health Savings Account) – An account that lets you save for future medical costs. Money put in the account is not subject to federal income tax when deposited. Funds can build up and be used year to year. They are not required to be spent in a single year. HSAs must be paired with certain high-deductible health insurance plans (HDHP).
Network Provider/In-network Provider – A healthcare provider who is part of a plan’s network.
Non-network Provider/Out-of-network Provider – A healthcare provider who is not part of a plan’s network. Costs associated with out-of-network providers may be higher or not covered by your plan. Even if you have coverage, not all doctors, labs or facilities may be in network.
Out-of-pocket Cost – Cost you must pay. Out-of-pocket costs vary by plan and each plan has a maximum out of pocket (MOOP) cost. Let’s say you have a $2000 with 80/20 coinsurance and max out of pocket cost of $4000. This means that you will pay the first $2000 up front. Then, you will pay 20% of all costs until you reach $4000 total for the year. At that point, insurance covers 100% of the rest of covered services.
When Insurance Isn’t an Option
Unfortunately, there are going to be many cases where insurance simply isn’t an option. So in that case, what can you do to help you achieve your dreams of having a family? Here are a few other options that may help you with the financial piece of infertility.
NOTE: These are just a few ideas. Please visit fertilityandbeyond.org and fertilityfoundationoftexas.org for more information on these options:
If you’re comfortable sharing your story, there are a variety of crowdfunding platforms such as Go Fund Me. While this will certainly make your personal story very public, it may be a great way to generate the funds necessary to proceed with your treatment plan.
The mission of the Fertility Foundation of Texas is to provide education, support and financial assistance for infertility treatment.
The Tree of Life Grant is also available for central Texas patients in the Jewish Community.
There are a number of other national and local grants and programs available depending on your personal situation, background and location, so it’s a good idea to do some digging to see what you might qualify for. Grants range from small amounts to possibly covering an entire treatment.
Please visit fertilityandbeyond.org for some additional grant opportunities.
Saving on Medications
There are often coupons or special promotions available directly from the drug companies or working with a specialty pharmacy. You may be able to get creative and save thousands of dollars on your medications (this holds true even if you have coverage for treatment, but not drugs).
Shared Risk/IVF Refund Programs
There are programs where you can possibly recoup your costs if treatments aren’t successful. You basically pay up front for multiple treatments, on average the number is 3. If you aren’t successful, you can get your money back.
There are some definite pros (like a refund if treatment is unsuccessful) and cons (like cost per cycle might be slightly more expensive) to these programs so be careful when considering them and be sure to read the fine print.
Nobody WANTS to take on more debt, but sometimes it’s the only option available. You may be able to qualify for a personal loan or line of credit to fund your treatment. Keep in mind, you will still need to pay it off and interest can add up, so shop for a low interest rate option.
In many cases, you’ll get offers from your credit cards for 18 month 0% transfers or cash advances. This is a potential option, but just be prepared to pay it off before the promotional experience expires (or transfer to another card) so you’re not hit with crazy high interest rates.
While you’re still paying out of pocket, you will essentially be able to “finance” the treatment over the course of the promotional period. So instead of paying, for example, $12,000 up front, you could pay $1000/month towards the balance.