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Fertility on a Budget

Lesson 4 of 6

Mechanics & Surprises of Fertility Coverage

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Costs Accrued Even With Insurance

A first principle to establish is that even if you have insurance that covers fertility treatment, you will almost certainly be accruing expenses. Let’s look at the example of someone who will do two IVF cycles in the same year and who has reasonably standard terms on their policy: $500 monthly premiums, a $5,000 deductible, and 20% co-insurance on a policy that covers $20,000 of treatment.

Plan Details

In cycle #1 (occurring between January and June), the patient paid $3,000 in premiums (6 months x $500) to have the plan in place. Given the $5,000 deductible hadn’t been met, the $5,000 drug charge fell to the patient. The clinic’s $10,000 charge for IVF was 80% covered by insurance and 20% by the patient. To this point, the patient’s paid $10,000 ($3,000 in premiums, $5,000 for drugs, $2,000 to the clinic.

January - June Cycle 1

Since 50%–90% of first cycles don’t work, the patient will likely cycle again, this time in the July–December time period. Again, they’ll have paid an additional $3,000 in premiums (6 months x $500). The patient met their deductible and is still under their fertility maximum (originally $20,000), so they’ll pay $1,000 (or 20%) of the drug bill. Similarly, when it comes time to pay the clinic, the patient is still under their fertility maximum (which is starting to dwindle) and will thus cover $2,000 (20%) of the $10,000 bill.

July - December Cycle 2

In total, the patient will have paid $16,000 while insurance covered $20,000. In this case, even with generous coverage, the patient shouldered the burden nearly dollar-for-dollar with the insurer.

Examples Two Cycles in a Year

Timing of Treatment Is a Variable

In the past example, a patient paid $16,000 for access to their plan and two cycles of treatment within the same year. As you’ll recall, deductibles reset annually so let’s look at how costs will accrue under the exact same plan but with treatment shifted back six months so that the two cycles occur in different years.

In this case, the patient now pays more than the insurer ($20,000 vs $16,000) largely because in Cycle #2 the deductible reset and the patient is forced to pay for this cycle’s drug costs despite still being well below the $20,000 fertility lifetime maximum.

When possible, and all things being equal, it’s generally best financially to have treatment spread out across as few years as possible.

Cycle at Year End then New Year

How Paying Out of Pocket Can Save Money

You’d be right to assume anytime you can get insurance to pay for fertility treatment, you should let them. However, confusingly, there are many circumstances where such a decision ends up being more costly in the long run. We’ll explain.

Clinics and pharmacies often have two sets of prices:

  • The “cash pay” price if you pay directly
  • The “contracted price” if your insurer is billed

Often, but not always, the “cash pay” price tends to be lower for many reasons including the pharmacy/clinic don’t need to exert effort and suffer delays to collect from the insurance company.

Sometimes the disparity can be enormous, and in those situations, sometimes it's best to pay out of pocket and preserve your “fertility lifetime maximum” dollars (rather than have them get chewed up by a high price quoted to your insurance company).

The disparity between the cash-pay price and insurance price tends to be particularly noticeable when it comes to fertility medications.

Let’s look at a situation where the same patient (with the same policy) has a decision: let their insurance company pay an inflated price for drugs (e.g. in this case, $10,000) or pay the lower “cash pay rate” (in this case, $3,000).

If insurance pays for the drugs, the fertility maximum gets chewed up quickly, and by the time the clinic gets paid, the patient spent $10,000 and their fertility maximum has been reached.

If the patient pays for the drugs out of pocket, by the time the clinic has been paid, the patient will have spent only $7,000 (vs. $10,000) and still have $4,000 remaining before hitting their maximum. See the chart below.

Example Pharmacy Gouging

This can also apply in the case where the cash-pay price at the clinic itself is lower than the contracted rate with the insurance. If a patient has a high-deductible plan, they may end up paying more using their insurance than if they had simply paid the clinic directly.

Generally speaking (but not always), it’s worth considering paying the cash pay price when:

  • Expensive injectable hormones are needed and drug coverage is included in your fertility maximum (as opposed to broken out separately)
  • Your fertility coverage is capped in dollars (rather than cycles)
  • There’s a major disparity between the cash-pay and contracted price insurance pays
  • You are earning tax-free interest in your HSA account and don't want to use that money if you don't have to.

Understanding Clinic Fees

The reality is most treatment expenses will be associated with your fertility clinic either in the form of physician fees (e.g. costs of visits) or laboratory fees (e.g. costs to grow embryos). Frustratingly, these are often billed from separate entities (which may have differing agreements with your insurer).

We suggest having a lucid, frank ,and concrete discussion with your clinic’s billing coordinator on a few items, which may require a separate conversation with your doctor when it comes to necessity.

Totality of Costs

Have your clinic break down all costs you're likely to accrue and what cost each party is likely to charge you. This should include anesthesia services from outside vendors and add-ons like ICSI, embryo biopsy for PGT, assisted hatching, and annual storage.

Again, while doctors may be reluctant to discuss costs, if the clinic intends to charge you for add-ons, having a candid discussion of their true necessity is critical.

Request In-Network for Outside Entities

While your clinic performs most of your treatment, they don’t perform it all. They often contract out the work for anesthesia to a third-party doctor group and if PGT is necessary, the work to read the embryo's sample is given to a “reference lab”.

These outside entities will generate their own bills, and if they’re “in network” with your insurance plan, the cost to you may be dramatically lower. In this case, it can be smart to request that the clinic first look to include service providers who are in your network.

Receiving a Diagnosis When One Exists

As you’ll recall, insurance policies that cover fertility treatment often require the patient to wait or undergo cheaper treatments before paying for more costly (and effective) approaches (e.g. IVF).

An exception is when the patient is diagnosed with an underlying condition that will render those approaches useless. Below is language from an actual policy.

You’ll recall from our course on unassisted conception (found here), there are certain requirements needed for unassisted conception to occur. A diagnosis that reflects unassisted conception isn’t possible may improve the odds a patient can bypass natural intercourse in favor of oral medical, bypass oral medication in favor of IUI, bypass IUI in favor of IVF, or bypass using one’s own gametes in favor of donor eggs, donor sperm or gestational surrogacy.

Requirements to Conceive Naturally

If a doctor believes a patient suffers from an infertility-related disease, it's important they “code” the diagnosis as such when paperwork is submitted to the insurance company. Therefore, asking your doctor and clinic to be certain to do this can be an important step.

For instance, a gay couple may be more likely to qualify for treatment if one partner is determined to have male factor infertility as ascertained by the semen analysis. Common disease states like endometriosis can impact a person’s ability to conceive or carry and so if they exist, it’s important that they be coded into the patient’s chart. In some circumstances, some of your treatment may be covered if the procedure is intended to treat “pain” or “irregular periods” but would not be covered to treat “infertility”.