Financing Infertility Treatment
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 treating infertility is, in many cases, a patient’s limited finances.
The issue is not so much the actual cost of certain procedures, like IVF, but rather the lack of insurance coverage available. In Texas, while it is mandatory that insurance companies offer employers the option to include infertility benefits, employers are not required by law to include coverage in their employee plans. Since many patients must pay out-of-pocket, the perception is that it is expensive relative to other medical procedures. In truth, one round of IVF is significantly less expensive than a partial knee replacement, for example.
If you find yourself facing infertility and seeking options for paying for your treatment, or if you are trying to help a friend or loved one navigate the financial aspect of infertility treatments, what follows are some tips and ideas that we have gathered from infertility patients who have faced the challenge of paying for their medical care.
First, call your insurance provider and ask them what IS covered in relation to fertility treatment. 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, even if the plan does not cover IVF or IUI.
It is possible that infertility benefits are included in your plan, so it certainly makes sense to at least ask. The worst thing the insurance company can tell you is that nothing is covered.
It is also important to be aware that coverage can be found on both the patient’s insurance as well as your spouse or partner’s plan, so you should always research and explore the possibility with regards to all plans under which you may have coverage.
Many patients are unaware that their spouse’s plan could cover infertility.
TIP: Call 2-3 times and ask the same questions. You don’t always get the same answers when calling your insurance company, unfortunately. It all depends on whom you speak to on the other end of the line.
Also, don’t rely only on the doctor’s office to get the answer for you. Their information is only as good as the representative to whom they spoke. Again, you do not always get the same information when you speak to different people. Many times coverage is found on a second inquiry when you re-verify benefits.
You can also talk to your employer’s Human Resource contact person to inquire about benefits. He/she may be more familiar with your plan and can be a good resource.
Ultimately, it’s a good idea to initially 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 worry whether or not you have coverage for a procedure you may not even need. You do not want to jump through all sorts of hoops to get coverage only to find out that it doesn’t cover your particular needs in the end. You should definitely work with your physician and their office staff to be clear on what procedure(s) you will require and to know in advance what is and is not covered by your insurance plan.
NOTE: While medications are often not covered in plans that DO include infertility treatment as a benefit, the medication costs will sometimes apply towards your deductible, so be sure to ask.
Which Insurance Carriers Cover Infertility
All insurance carriers offer about the same coverage to employers.
In the state of Texas, you cannot purchase coverage as an individual.
The only option is to find an employer who offers coverage, convince your current employer to add the coverage, or purchase a group health insurance plan if you are 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, making it much less expensive than paying out of pocket for infertility treatments.
Types of Insurance Plans in Texas
There are two types of employer insurance plans:
1. Fully insured policies; and
2. Self-funded policies.
Fully Insured Policies
Fully insured policies are designed and offered by the insurance company and purchased by the employer. Plans that are “fully insured” are overseen by the Texas Department of Insurance.
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 to apply for this coverage exception directly from the insurance carrier. It is also a very good idea for patients to include a letter from their physician explaining 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 an “insurance” complaint against the employer).
If you’re covered under a “self-funded” plan, understand that the ultimate decision on whether to extend benefits 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 your employer’s HR or benefits 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 crucial to find an agent with experience in infertility coverage. Unfortunately, the majority of agents do not have this experience and may provide misleading – or bad – information to patients. While not intentional, it can be extremely costly when you rely on bad information.
Always ask to read the rider in detail to make sure your needs are going to be met by a particular policy before you buy it. The last thing you want to do is to purchase an expensive policy that does not provide what you ultimately need.
This is why it’s pertinent to get a diagnosis BEFORE procuring policies or getting exceptions to your policy. You may think you will need IVF, but find out after diagnostic testing, that you require an alternative procedure.
In addition, coverage is available separately for the medical services associated with infertility AND the necessary medications. A knowledgeable agent should be able to identify all coverage options available to you.
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 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). 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 deductible 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 should cover 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.
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 treatment for qualified Central Texas infertility patients. Visit: www.FertilityFoundationOfTexas.org for more information.
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.
Saving on Medications
There are often coupons or special promotions available directly from the drug companies or in 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 three. 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 can find promotional offers from credit card companies. You may get an offer from a credit card company 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 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. Instead of paying, for example, $12,000 up front to the medical provider, you could pay $1000/month towards the balance on your credit card.
We hope that some of these ideas that have been shared with us will get you thinking. Please talk to others, consult a financial expert, and learn more on your own to help you solve the financial obstacles to accessing medical care.