If you’re considering pursuing fertility treatments, one of the first steps is understanding your insurance coverage. Every fertility insurance provider is different, so a procedure that is covered by one provider may not be covered by another. If you’ve found the best insurance for infertility treatments, you can change your coverage during open enrollment.
Affording care: the cost of fertility treatments
Before beginning fertility treatments, many patients want to know: how much will this cost? Unfortunately, there’s no one-size-fits-all answer. The cost of your treatment will depend on the type of insurance you have, as well as the type of procedures and medications your doctor recommends.
Fertility treatment is not uncommon. According to Kaiser Family Foundation, about 10% of patients receive medical help to become pregnant. However, not all procedures are covered for all patients.
For example, some insurance providers cover treatments like in vitro fertilization (IVF) and intrauterine insemination (IUI), while others do not. Providers may cover fertility treatments but set a dollar limit on coverage, such as a $15,000 lifetime limit.
Fertility costs and open enrollment: What you need to know
Insurance providers typically offer an open enrollment period once a year when participants can sign up for, change, or drop their coverage. If you miss this window, you’ll have to wait until the following year to change your insurance plan unless you have a “qualifying event,” such as getting married or divorced.
How do I choose & enroll in a new plan?
If you’re thinking about switching plans, ask your insurance provider for an enrollment guide or plan information to compare and contrast your different options. Here are a few factors you may want to consider:
- What are the plan’s deductible and out-of-pocket maximum?
- Which fertility treatments are covered?
- Are fertility medications covered?
- Are there any eligibility requirements or limitations to fertility benefits, such as age or preexisting conditions?
- What is the lifetime limit on fertility treatments?
- Is your fertility provider included in the insurance carrier’s network?
Your provider or employer may also host informational sessions where you can learn about the different plans available to you or have a helpline that you can call.
Other financing options & programs backed by RMA
If you cannot change your insurance coverage at this time, there are other options to help you cover the cost of fertility treatment. RMA Network assigns each patient a financial coordinator to help them understand the ins and outs of fertility financials.
Fertility Financing
Some fertility clinics, such as RMA Network, participate in consumer lending programs that help patients pay for fertility treatments through flexible loans. While financing programs vary by practice and are subject to change, RMA Network’s current partners include:
- Lending Club Patient Solutions
- ARC Fertility
- Prosper Healthcare Lending
- Future Family
- Fertility Access
The RMA Network staff can meet with patients and their partners to discuss their financing options and the various payment plans available to them.
You may also be able to apply for a grant or scholarship to help offset or cover the cost of treatment. RESOLVE, a national non-profit organization dedicated to supporting families experiencing infertility maintains a list of scholarships and grant programs for patients trying to grow their families. Eligibility for each program varies, so patients should contact these funders directly with questions.
Patients who choose IVF treatment can apply for CareShare, our IVF Refund Program, at certain RMA Network practices. While CareShare costs more than one cycle of IVF, it pays for itself if you need more than one cycle to get pregnant and deliver a healthy baby.
CareShare covers up to six IVF cycles. If IVF isn’t successful after all six cycles, you’ll get all your money back. This program includes the following treatments:
- IVF procedures (up to six)
- Frozen embryo transfer (as available)
- Intracytoplasmic Sperm Injection (ICSI)
- Embryo biopsy
- Embryo cryopreservation for the first 18 months
- Pre-implantation Genetic Testing for Aneuploidy (PGT-A)
- Cycle monitoring
If you are interested in CareShare, you should talk with your primary RMA Network physician, who can help determine your eligibility. Once you’re enrolled in CareShare, you will be required to waive fertility insurance coverage for any services provided as part of the CareShare package.
RMA Network serves patients in California, Florida, New Jersey, Pennsylvania, Texas, and Washington. To learn more about fertility treatment, insurance, and receiving care through RMA Network, contact us today.
Are all benefit plans the same?
No, all benefit plans are not the same. Employers drive what specific benefits and services are offered to employees. The best place to start learning about your benefits is to meet with your HR team or employee benefits coordinator.
Do I need to choose a new plan? How do I know which one to choose?
Benefits cannot be verified until a policy is in effect, but we’re happy to provide general information about an insurance carrier. We suggest comparing premium costs, deductibles, copays, co-insurance, maximum out-of-pocket expenses, and covered services. Also, be sure to check your pharmacy benefits to see if the plan covers fertility drugs.
Open enrollment is a good time to consider adding a flexible spending account (FSA) for costs not covered by insurance, like deductibles and co-pays. However, your FSA may limit how or when you use these funds. As always, you should check with your employer benefit coordinator to make sure you understand the terms of your particular FSA.
What if I’m on the same plan as last year?
Not all authorizations extend to the new year. Let your financial coordinator know if your out-of-pocket maximum or deductible is changing, so we can calculate with the assumption that those amounts reset with each new year.
If you reached your out-of-pocket maximum in 2021 and have not been paying copays, we will reset your account and begin collecting copays again in 2022.
Anything else I should know?
Some insurers determine coverage based on specific medical criteria, including a history of infertility. They may also require you to do a certain number of intrauterine inseminations (IUI) before approving in vitro fertilization (IVF), so be sure to read the details of the policy.
You may inquire by the treatment-specific codes: Intrauterine Insemination (IUI) is 58322, necessary egg retrieval for IVF is 58970, and intracytoplasmic sperm injection (ICSI) is 89280.
My insurance plan is changing on 1/1/23. What should I do?
Unfortunately, insurance carriers will not quote any benefit information or provide authorizations before the plan is in effect. If you anticipate this being an issue, please talk to your nurse about adjusting your start date (the date you start injectable medication or Estrace).
Keep in mind that billing dates are always determined by the date of service. If you start your medication before 1/1/23, the bill will reflect the date the services were rendered.
If your retrieval, transfer, or insemination occurs after the new year, it will be billed with the date the services were rendered, NOT with the date you started your cycle.
Any services, including any bloodwork, will be billed when the services are rendered.
