Thursday, November 11, 2010

Dollars and Cents: Affording Infertility Treatments

I was contacted by a reader desperate for some information on affording infertility treatments. Considering the cost of treatments and everything that precedes and follows an actual IUI or IVF, I hope this entry will be helpful to many of you (who reside in the US).

Insurance Coverage/Plans:

First I want you to read your insurance plan very carefully. Unlike the owner's manual to your television, when it comes to your insurance plan, the fine print could give you the most important information regarding infertility coverage.

Find out if you live in an infertility treatment mandated state. For instance, New York provides mandated coverage for IUIs and medications. While Massachusetts residents will be also covered for IVF. Don't limit yourself to your state of residence -- if your employer is in a mandated state, they must offer infertility coverage (let's say you live in NY but work in Connecticut). Some insurers will cover at various percentages while others will give you a "lifetime" maximum amount of dollars to go towards your infertility treatments.

If you are lucky enough to have coverage, make sure there aren't any provisions and pre-requesits to the coverage. In some fashion, they will ask that you prove your infertility. (No, they do not read your blog, but they should.) Also, when you're gearing up for a cycle, make sure you check with your insurer to obtain a cycle number and that you have a letter confirming your coverage for that pending cycle.

Even if infertility treatments aren't covered, some tests (blood or surgical) are often times part of your basic coverage. So for instance, if your RE recommend a hysteroscopy but your insurer won't pay for it if it's done by a specialist, don't be afraid to seek the help of your gynecologist to perform the recommended procedures or tests.

If you're required to pay out-of-pocket to then get reimbursed by your insurer, you have to stay on top of it like your life depends on it (in this case, your wallet). Many insurers will deny claims, to eventually approve them after you've spent hours fighting about it. If you know your coverage inside out, you will be surprised at how much more you know than the representative on the phone. I've said this on countless occasions: you must be your strongest advocate.

With the upcoming changes in the Health Care Bill taking effect in 2014, you will no longer be denied insurance for preexisting conditions. But keep in mind that if  infertility coverage is part of your current plan, it will most likely be dropped by 2014. Universal health care may be coming at the cost of your infertility coverage.

Lastly, if your employer has not signed up to cover infertility, then pick up the phone and call HR. Make your case. Sixty five percent of employers who cover IF said they do so because their employees asked for it. So, petition your employer for IF coverage. Here's a sample letter.


Some pro-bono agencies provide infertility coverage grants offered by Fertile DreamsINCIID and the Cade Foundation. They come with strings attached and are incredibly selective (at times discriminating). But it's certainly worth the shot. Before you commit to any program, be mindful of the restrictions that are involved with pro-bono grants. Here's a link to important questions to ask when reviewing your grant options.

Shared-Risk Programs:

When you take into account the exorbitant cost of multiple rounds of IVF, some clinics and third-party companies are offering what they call "shared-risk programs" or package-deals. These programs cover multiple cycles with a money-back-guarantee if none of the cycles end in a live-birth. Expect to pay a larger sum upfront but you will have peace of mind knowing that you have 4-6 cycles before it all runs out. Depending on the plan offered, after 2 cycles, the consecutive cycles come to a fraction of the cost of just one cycle. Keep in mind though that these programs, similarly to grants, are very selective (FSH, age, past history and reasons for the infertility will be closely scrutinized). Also, they will not cover preliminary tests, medications and certain aspects of the cycle (like the anesthesia).

On a personal note, after paying for 4 IUI and 4 IVF cycles mostly out-of-pocket, we opted for a shared-risk program. The program initially rejected us but we pleaded our case via our new RE. They accepted us, we payed $30K. The first cycle with the program worked.

Other Options:

Medications -- All clinics have donated or left-over medications (injectables or otherwise). This is the time to work your people skills with your nurses. Also, when your RE calls in for your drugs, they often don't qualify whether they approve generic or brand name. Generic drugs are just as effective as brand names and cheaper.

Flexible-Spending Accounts -- Employers offer flexible spending accounts. Use them! If you know you're going to do a cycle (or more), a flexible spending account will allow you to put some of your hard earned pre-taxed money towards your treatments.

401(k) -- Some 401(k) plans allow you to dip into your savings for medical purposes without any tax penalties. This should be a last resort option as you are taking a great risk by dipping into your future for treatments that cannot guarantee success.

Clinical Trials -- Fertility clinics have on going clinical trials. Ask your RE if they are working on any trials that you may qualify for. Make sure you understand what's involved, what's covered and how beneficial it will be to you.

Create an Infertility Fund -- How many of us have received useless gifts for holidays and birthdays. If you have come out to your loved ones about your struggles, I would encourage you to open up an infertility fund. This is also the time to reach out to your community. You may be surprised by the outpouring of support. In the same spirit, contribute to your own fund by doing some spring cleaning. You must have countless things that are buried in the depths of your closet (or house) that you have not touched in ages. Put them up on eBay or do a yard sale.

Lastly, keep records of all of your infertility related expenses and all other medical expenses. If they add up to more than 7.5% of your adjusted gross income, you will receive tax benefits.


Alex said...

Great post - very helpful!

Jules said...

So if a company is headquartered in a mandated state, even though I work in a non-mandated state, they have to cover my IVF?

For instance, my employer's corporate headquarters are in Maryland. I live in Colorado. Thanks!

The Infertility Doula said...

Alex, glad to be of help.

Jules, unfortunately you have to be working at the office location that has the mandate. Sorry :(

Jules said...

On second read, I see that I kind of had it backwards. Oh well.

Thanks for this information, though. Wonderful post!

Esperanza said...

I am fortunate enough that I've not yet needed to turn to ART but if I ever do, I will be rereading this post. What amazing information. Thank you so much for presenting it so thoughtfully and so well.

Kevin H - Infertility Insurance said...

I believe Jules' interpretation is correct. You read so many posts from people who live in mandate states but don't have coverage because their employer is headquartered in a non-mandate state. Group health insurance is regulated by the laws in the state where the policy is issued - usually the headquarter state of the employer. Otherwise a group health plan might need to conform to 50 different sets of rules.

On another note - couples should concentrate their expenses into a single tax year when possible, rather than spreading these expenses. This way they get better tax savings on the amounts over 7.5% of adjusted gross income.

Thanks for all the great suggestions!

The Infertility Doula said...

Kevin, thank you for your input. While you are in part correct, I know from personal accounts that even if the headquarters are in a mandate state, the satellite office doesn't always offer IF benefits. I guess this goes to show that companies make the rules up to suit their needs.

And yes, definitely file jointly in order to amount to 7.5%

gingerandlime said...

Thanks for this! Very informative.

Keya said...

What a great post. Thanks for all the info. One quick question - with the health care changes coming up, does that mean the mandated states will no longer be mandated? I live in Illinois, which has mandated coverage. Was just off to read more of your enlightening posts!

TeamBabyCEO said...

Hi there-my employer is in a mandated state (IL) where I live in a non-mandated state. I do have insurance coverage-best to check with your insurance company, and be prepared to ask very pointed questions and ask for documentation describing coverage/limits.

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